BIO: 

LIBRARY 


A   LAYMAN'S   HANDBOOK  OF 
MEDICINE 


A  LAYJVM^S  HANDBOOK 
OF  MEDICINE 

WITH  SPECIAL  REFERENCE 
TO  SOCIAL  WORKERS 

BY 

RICHARD  C.  CABOT,  M.D. 

Author  of  "What  Men  Live  By  " 


WITH  ILLUSTRATIONS 


BOSTON  AND  NEW  YORK 

HOUGHTON  MIFFLIN  COMPANY 


1916 


COPYRIGHT,    1916,   BY   RICHARD   C.    CABOT 
ALL,    RIGHTS   RESERVED 

Published  December  iqib 


PREFACE 

To  boil  medicine  down  to  the  essentials  needed  by 
the  general  public  and  yet  to  avoid  making  it  taste- 
less is  my  attempt  in  this  book.  It  is  too  long;  but  I 
could  not  make  it  shorter  without  also  making  it 
duller. 

Not  everything  in  it  is  "  practical,"  for  one  of  the 
public's  needs,  as  I  see  them,  is  to  get  a  glimpse  of 
some  amazingly  interesting  aspects  of  medicine  which 
have  little  or  no  practical  value.  The  pages  on  com- 
parative anatomy,  the  tragic  facts  of  anaphylaxis 
and  some  other  passages  were  written  out  with  this 
belief. 

"A  little  knowledge  is  a  dangerous  thing."  Yes;  it 
certainly  is.  But  since  every  body  and  soul  in  the 
civilized  world  has  now  been  thoroughly  exposed  to 
this  dangerous  contagion,  I  know  no  way  to  reduce 
the  risk  of  disaster  except  by  injecting  into  all  who 
will  submit  a  larger  dose  of  knowledge  in  the  least  irri- 
tating form  procurable.  Gradually  I  hope  an  im- 
munity to  its  dangers  may  thus  be  produced. 

Part  of  the  book  was  given  during  1915  and  1916 
in  the  form  of  lectures  to  a  group  of  social  workers; 
their  needs  have  guided  my  selection  of  subject  mat- 
ter because,  as  I  see  it,  they  best  represent  the  gen- 

v 

355298 


PREFACE 

eral  public.  For  the  same  reason  their  questions  and 
the  answers  given  to  them  have  been  made  part  of 
the  book. 

The  illustrations  are  rough  and  sketchy  but,  I  hope, 
worth  their  space.  I  here  thank  Messrs.  D.  Appleton 
&  Co.  for  the  use  of  the  cuts  used  in  Figs.  I  and  2 
and  W.  B.  Saunders  Co.  for  a  diagram  of  the  ear. 

RICHARD  C.  CABOT 

i  MARLBORO  ST.,  BOSTON 
November,  1916. 


CONTENTS 


CHAPTER  I 
ANATOMY  AND  PHYSIOLOGY 

INTRODUCTION I 

THE  SKELETON 2 

THE  MUSCLES 12 

CONTENTS  OF  THE  CHEST  AND  ABDOMEN 13 

THE  HEART  AND  LUNGS 15 

RESPIRATION 18 

THE  DIGESTIVE  TRACT 26 

THE  LIVER 34 

THE  URINARY  ORGANS 36 

THE  GENITAL  ORGANS 38 

THE  NERVOUS  SYSTEM 45 

CHAPTER   II 
DISEASES  OF   THE   RESPIRATORY   SYSTEM 

DISEASES  OF  THE  TONSILS: 

Tonsillitis 43 

Quinsy  sore  throat 50 

Hypertrophied  tonsils  and  adenoids  in  children         .      .       .       .  .51 

DISEASES  OF  THE  NASAL  CAVITIES,  CATARRH 53 

LARYNGITIS 55 

DISEASES  OF  THE  LUNGS: 

Tuberculosis 57 

Bronchitis 57 

Bronchiectasis 59 

Coughs 59 

Asthma .       .  61 

Emphysema 62 

Empyema 63 

Pleurisy 63 

Pneumonia 66 

CHAPTER  III 
DISEASES   OF  THE   HEART  AND  ARTERIES 

DISEASES  OF  THE  HEART 67 

Rheumatic  heart  disease  (endocarditis) 68 

vii 


CONTENTS 

Syphilitic  heart  disease 70 

Arteriosclerotic  heart  disease 70 

Nephritic  heart  disease 72 

DISEASES  OF  THE  ARTERIES:  g 

Arteriosclerosis 76 

Aneurism 79 

VARICOSE  VEINS  (VARICOSE  ULCER) 80 

CHAPTER  IV 

DISEASES   OF  THE  GASTROINTESTINAL  TRACT 
THE  MOUTH: 

Diseases  of  the  teeth: 

Riggs'  Disease 84 

Caries ,       ...     86 

Impacted  teeth 88 

Hutchinsonian  teeth 90 

Diseases  of  the  tongue  (cancer,  tuberculosis,  syphilis)     ...    92 

Diseases  of  the  throat 92 

Diseases  of  the  esophagus: 

Cancer 93 

Corrosive  stricture 94 

Spasmodic  stricture 94 

Diseases  of  the  stomach:        ' 

Cancer  .  95 

Ulcer 97 

Gastritis IOI 

Stomach  symptoms  caused  by 

Nervousness 103 

Diseases  of  the  brain 105 

lungs 107 

heart 108 

liver •   .      .      .      .  108 

intestine 109 

kidney 109 

Industrial  diseases,  and  . 109 

Diseases  of  the  blood no 

CHAPTER  V 

DIET  —  CONSTIPATION 
DIET in 

Three  classes  of  foods 112 

Indigestible  foods 114 

Quantity  of  food 117 

Selective  action  of  the  stomach 119 

Calory  value  of  foods .       .       .       .  121 

Adulteration  of  food      .  125 

viii 


CONTENTS 

Scurvy,  beri-beri,  and  vitamins 126 

Exercise  after  food 128 

Diet  and  constipation 128 

CONSTIPATION: 

Intestinal  effects  of  emotion 132 

Habit  formation 133 

Laxatives  and  purgatives    . 134 

Effects  of  constipation         . 136 

CHAPTER  VI 
DISEASES   OF  THE  LIVER  AND   INTESTINE 

DISEASES  OF  THE  LIVER:    ' 

Gall-stones  (jaundice) 137 

Cirrhosis 145 

Abscess  of  the  Liver 147 

Hydatid 147 

Catarrhal  jaundice 148 

DISEASES  OF  THE  INTESTINE: 

Appendicitis 149 

Inflammation   of  the    intestine    (colitis,    enteritis,    dysentery, 

nervous  diarrhea) 153 

Tuberculosis 157 

Intestinal  obstruction 157 

CHAPTER  VII 

DISEASES   OF   THE   KIDNEY  AND    BLADDER 

DISEASES  OF  THE  KIDNEY: 

Bright's  disease,  acute  and  chronic  (apoplexy) 161 

Floating  kidney 172 

Tuberculosis  of  the  kidney 173 

Pyelitis 177 

DISEASES  OF  THE  BLADDER: 

Cystitis 178 

Tumors 179 

CHAPTER  VIII 

DISEASES   OF   THE    GENERATIVE   ORGANS 

FEMALE: 

Tumor  of  the  uterus 180 

Cancer  of  the  uterus 183 

Inflammation  of  and  through  the  uterus 184 

Endometritis 185 

Diseases  of  the  cervix 1 86 

Lacerations  of  the  perineum 187 

ix 


CONTENTS 

Diseases  of  the  Fallopian  tube 189 

Peritonitis 192 

Cystocele  and  rectocele 195 

Prolapse  of  the  uterus .       .196 

Vaginitis 196 

Ovarian  disease: 

Tumor 198 

Prolapse 201 

Extra-uterine  pregnancy 201 

The  Hygiene  of  Pregnancy 203 

Disturbances  of  menstruation 204 

Abortion 205 

MALE: 

Gonorrhea 208 

Prostatic  obstruction     .      ..       . 212 

Varicocele 214 

BIRTH  CONTROL         214 

SEPTIC  PERITONITIS 216 

CHAPTER   IX 

DISEASES   OF  THE   NERVOUS   SYSTEM 

MOODS 218 

PSYCHONEUROSES       .  219 

Neurasthenic 221 

Hysteric 222 

Psychasthenic 227 

Traumatic 228 

Visceral .       .      .      .      .  229 

PSYCHOSES: 

Manic  depressive 233 

Exhaustive 240 

Parturient 241 

CHAPTER  X 

DISEASES   OF  THE   NERVOUS   SYSTEM   (continued) 

INSANITIES 242 

Precocious  dementia 243 

Syphilitic  dementia 245 

Senile  and  arteriosclerotic  dementia 248 

Paranoia 249 

Alcoholic  insanity    .       .       . 251 

MENTAL  DEFICIENCIES 253 

DISEASES  OF  THE  BRAIN: 

Apoplexy 256 

Syphilitic  disease  of  the  brain 258 

X 


CONTENTS 

Brain  tumor 258 

Meningitis  (tuberculous,  aural,  epidemic) 259 

CHAPTER  XI 
DISEASES  OF  THE  NERVOUS   SYSTEM  (continued) 

DISEASES  OF  THE  SPINAL  CORD: 

Tabes  dorsalis 265 

Spastic  spinal  paralysis 272 

Poliomyelitis 273 

DISEASES  OF  THE  PERIPHERAL  NERVES 276 

Alcoholic  neuritis 277 

Epilepsy     .  279 

Migraine 285 

CHAPTER  XII 

DIABETES,    DISEASES   OF  THE   BLOOD,    DISEASES  OF 
THE   BONES   AND  JOINTS 

DIABETES 288 

DISEASES  OF  THE  BLOOD: 

Anemia  (secondary,  pernicious,  chlorosis) 295 

Leucemia ,         302 

Purpura 302 

Hemophilia 303 

DISEASES  OF  THE  LYMPH  GLANDS 304 

Cervical  adenitis  (from  teeth,  tuberculosis,  syphilis,  malignant 
disease 305 

DISEASES  OF  THE  THYROID  GLAND: 

Goitre 306 

Myxedema 311 

DISEASES  OF  THE  BONES  AND  JOINTS: 

Tuberculosis  of  the  bones 312 

Tuberculosis  of  the  spine 314 

Syphilis  of  the  bones  and  joints 317 

Rickets 318 

CHAPTER    XIII 
DISEASES   OF  THE   BONES  AND  JOINTS    (continued) 

DISEASES   OF  THE   MUSCLES 
DISEASES  OF  THE  BONES  AND  JOINTS  (continued): 

Fractures 322 

Arthritis 324 

Infectious  (tuberculous,  rheumatic,  gonorrheal)     ....  325 
Hypertrophic  (Heberden's  nodes) 327 

xi 


CONTENTS 

Atrophic 329 

Gouty 330 

Traumatic 331 

Osteomyelitis 333 

Sacro-iliac  strains,  sprains,  etc. .  335 

Scoliosis 337 

Flat  foot 338 

Bunions       . 339 

DISEASES  OF  THE  MUSCLES: 

Trichiniasis 339 

ANIMAL  PARASITES: 

Tapeworm 341 

Pinworms 342 

Round  worm 342 

Hookworm 342 

CHAPTER  XIV 

INFECTIOUS  DISEASES 

INFECTIOUS  FEVERS: 

Sepsis 345 

Typhoid  fever 346 

Diphtheria 349 

Scarlet  fever 353" 

Measles 357 

Chicken-pox 358 

Whooping-cough 359 

Gonorrhea 361 

Syphilis,  congenital  and  acquired 365 

CHAPTER  XV 
INFECTIOUS  DISEASES   (continued) 

Malaria  (tertian,  estivo-autumnal) 382 

Septicemia 389 

Erysipelas 394 

Tetanus 395 

Anthrax 398 

Leprosy 400 

Smallpox 402 

CHAPTER  XVI 

POISONS 
POISONS: 

Lead  poisoning 407 

Naphtha  poisoning 411 

xii 


CONTENTS 

Acetanilid  poisoning 411 

Alcoholism 412 

Opium  (morphine,  heroin)          424 

Cocaine 433 

CHAPTER  XVII 

INDUSTRIAL  DISEASES  —  SKIN  DISEASES 

INDUSTRIAL  DISEASES 435 

Dust 437 

Caisson  disease 439 

Diseases  due  to  heat  and  cold 443 

Muscular  strains 443 

Occupational  skin  diseases 444 

Occupational  neuroses 444 

Industrial  overstrain 446 

DISEASES  OF  THE  SKIN: 

Pruritus 447 

Erythema 447 

Macule,  papule,  pustule,  vesicle 447 

Eczema 447 

Acne 449 

Boils 450 

Carbuncles 451 

Impetigo 451 

Pediculosis 452 

Scabies 453 

Dermatitis  venenata 453 

Psoriasis 453 

Urticaria 454 

Anaphylaxis 454 

CHAPTER  XVIII 
DISEASES   OF  THE   EYE  AND   EAR 

THE  EYE: 

Anatomy 457 

Conjunctivitis 459 

Interstitial  keratitis 461 

Phlyctenular  conjunctivitis  and  keratitis 461 

Iritis 462 

Cataract 464 

Retinitis 465 

Neuritis 466 

Squints  and  headaches 468 

Astigmatism 468 

Myopia 469 

xiii 


CONTENTS 

Hypermetropia 469 

Glaucoma 470 

Trachoma 471 

THE  EAR: 

Otitis  media 472 

Broken  ear  drum 474 

Syphilitic  disease  of  the  ear 476 

Inherited  deafness 476 

CHAPTER  XIX 
EMERGENCIES  —  HOME  MEDICINE — PERSONAL  HYGIENE 

EMERGENCIES: 

Choking 477 

Control  of  bleeding 478 

Cuts 483 

Bruises 483 

Sprains 484 

Unconsciousness 485 

Fits 485 

Convulsions 486 

Sunstroke 486 

Heat  exhaustion 488 

Burns 488 

Frost  bites 489 

Poisoning          489 

Drowning 490 

Bee  sting  .      .       .       .       .       .       . 492 

HOME  MEDICINE 493 

PERSONAL  HYGIENE: 

Sleep 493 

Food 496 

Exercise 497 

Bathing 498 

Clothing 499 

Menstruation 500 

Rest,  recreation,  vacation 501 

CHAPTER  XX 
MISCELLANEOUS   AILMENTS,   TRIVIAL  OR   SEVERE 

COMMON  COLDS          504 

VASOMOTOR  RHINITIS 504 

HANG-NAIL  AND  PARONYCHIA 504 

IN-GROWING  TOE  NAIL 505 

BURSITIS  ABOUT  THE  SHOULDER 505 

SHINGLES -.  506 

xiv 


CONTENTS 

CHOREA  AND  HABIT  SPASM 506 

HERNIA 507 

HARE-LIP,  CLEFT  PALATE,  AND  OTHER  CONGENITAL  DEFORMITIES  .  508 

ENURESIS 508 

STAMMERING 510 

MARASMUS 510 

STILL-BIRTH 510 

STARVATION         511 

OBESITY 511 

CANCER  OF  LIP  512 

CANCER  OF  RECTUM 512 

CANCER  OF  BREAST 512 


LIST  OF  FIGURES 

I,  2.  LEG  BONES  OF  VARIOUS  ANIMALS  ARRANGED  TO  SHOW  THE 
CORRESPONDING  PARTS 4 

Reproduced  by  permission  of  D.  Appleton  &  Company  from  Jordan  and 
Kellogg' s  Evolution  and  Animal  Life. 
Copyrighted,  1907,  by  D.  Appleton  &  Company. 

3.  TO  SHOW  HOW  THE  SCAPULA  IS  JOINED  BY  MUSCLES  TO  THE 

BACKBONE 5 

4.  SPINAL  COLUMN 6 

5.  DIAGRAM  TO  SHOW  RELATION  OF  SPINAL  CORD  AND  NERVES 

TO  VERTEBRAL  COLUMN 8 

6.  BREAST  BONE,  BACKBONE,  AND  RIBS 9 

7.  PELVIS  AND  HIP  JOINTS 10 

8.  To  SHOW  HOW  BICEPS  is  FASTENED  TO  THE  BONES  AT  EACH 

END  AND  HOW  BY  CONTRACTING  IT  PULLS  UP  THE  FOREARM  .    II 

9.  THE  BODY  CAVITY  DIVIDED  BY  THE  DIAPHRAGM       .      .      .14 
10.  DIAGRAMMATIC  SKETCH  OF  THE  HEART  AND  GREAT  VESSELS  .    15 
n.  DIAGRAMMATIC   CROSS-SECTION   OF   AN    IMAGINARY   ORGAN 

SOMEWHAT  LIKE  THE  SPLEEN 17 

12.  THE  FRONT  WALL  OF  THE  CHEST  REMOVED  TO  SHOW  THE 

POSITION  OF  THE  HEART  AND  LUNGS 18 

13.  DIAGRAMMATIC  SKETCH  OF  THE  OPENINGS  OF  WINDPIPE  AND 

GULLET 22 

14.  IMAGE  OF  THE  LARYNX  AS  SEEN  IN  MIRROR  HELD  ABOVE  IT    .  23 

15.  TRACHEA,  BRONCHI,  AND  THEIR  BRANCHES  IN  THE  LUNGS  .      .  24 

1 6.  BRONCHIOLE  AND  ALVEOLI 24 

17.  THE  TONSILS 25 

18.  GULLET         26 

19.  CONTRACTED  EMPTY  STOMACH 27 

20.  DISTENDED  STOMACH .  J  .  27 

xvii 


LIST  OF  FIGURES 

21.  PANCREAS  AND  DUODENUM 28 

22.  THE  COURSE  OF  THE  LARGE  INTESTINE 29 

23.  KIDNEY  AND  URINARY  COLLECTING  TUBES 37 

24.  URETERS 38 

25.  FEMALE  GENITALS  IN  CROSS-SECTION     ......  39 

26.  FEMALE  GENITALS 40 

27.  CROSS-SECTION  OF  MALE  GENITALS 43 

28.  DISEASED  TEETH  AND  NORMAL  TEETH  ......  90 

29.  DIAGRAM  TO  SHOW  CONNECTION  OF  GALL  BLADDER  AND  PAN- 

CREAS WITH  THE  INTESTINE 139 

30.  CROSS-SECTION  OF  THE  EYE 457 

31.  SEMIDIAGRAMMATIC  SECTION  THROUGH  THE  RIGHT  EAR  .      .  472 

After  Czermak 


A   LAYMAN'S  HANDBOOK  OF 
MEDICINE 


A  LAYMAN'S  HANDBOOK 
OF  MEDICINE 

CHAPTER   I 

ANATOMY  AND   PHYSIOLOGY 

ANY  one  who  studies  the  human  body  soon  becomes' 
aware  of  two  opposite  and  extraordinary  things :  first; 
that  it  is  full  of  beauties  and  extremely  useful  con- 
trivances, and  second,  that  it  contains  a  number  o{- 
blunders.  Any  one  who  is  bound  to  think  that  it  is  the% 
work  in  toto  of  an  intelligent  Creator  here  confronts  a*- 
hopeless  difficulty.  But  any  one  who  goes  to  the  othe/ v 
extreme  and  thinks  that  it  is  the  product  of  chance* 
evolution  is  in  another  hopeless  difficulty,  as  I  see  it. 
Hence  I  cannot  face  the  fact  of  the  body's  beauty  and 
usefulness,  and  also  the  fact  of  its  ugliness  and  mis- 
takes, without  saying  something  on  the  relation  of  the 
body  to  God. 

The  relation  of  our  bodies  to  God  is  somewhat  like 
the  relation  of  our  souls  to  God.  We  do  not  expect  that 
our  souls  will  be  perfect.  Our  bodies  are  a  part  of 
nature  and  need  not  be  assumed  to  be  perfect.  Pre- 
sumably bodies  and  souls  have  a  certain  amount  of 
freedom  whereby  they  can  go  wrong.  I  see  the  body, 
like  a  great  deal  of  the  rest  of  nature,  heroically  trying 
to  do  right,  often  with  extraordinary  success,  some- 


A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

times  with  pitiful  failure;  and  I  find  this  in  no  way  ir- 
reconcilable with  a  belief  in  God.  But  I  should  find  it 
impossible  if  I  did  not  recognize  that  element  of  free- 
dom to  go  wrong  which  I  think  is  present  in  the  whole 
of  nature,  and  which  I  think  makes  nature  sometimes 
beautiful,  sometimes  cruel,  sometimes  badly  contrived, 
and  sometimes  marvellously  ingenious. 

Anatomy  begins  with  the  skeleton  because  it  is  the 
easiest  part  to  keep  and  handle,  but  the  first  thing  to 
know  about  the  human  skeleton  is  that  it  is  really 
formed  last.  We  have  the  idea  of  the  dry  bones  be- 
coming clothed  with  flesh;  the  opposite  is  the  fact. 
The  soft  flesh  gradually  makes  within  itself  a  skeleton. 
The  baby  is  born  practically  with  no  skeleton;  some 
of  the  smaller  animals  never  have  much  of  any.  In 
man  the  skeleton  is  gradually  developed  as  it  is  needed. 

There  are  two  kinds  of  skeletons  in  the  animal  king- 
dom, those  arranged  on  the  outside  and  those  fixed  on 
the  inside.  We  have  both.  The  lobster  has  a  skeleton 
on  the  outside  and  keeps  his  soft  parts  inside  it.  This 
type  of  skeleton  restricts  movement,  but  has  great  ad- 
vantages from  the  point  of  view  of  protection.  Our 
skeleton  is  worked  out  to  combine  the  two  advantages 
so  far  as  possible.  It  is  on  the  outside  of  the  brain,  like 
the  lobster  or  tortoise  skeleton,  because  our  brain 
needs  protection  more  than  any  other  part  of  our  body, 
yet  does  not  need  independent  motion  or  flexibility. 
We  have  a  skeleton  of  the  inside  type  in  parts  of  the 

2 


ANATOMY  AND   PHYSIOLOGY 

body  where  bone  is  useful  for  support  and  the  attach- 
ment of  muscles.  Animals  that  do  not  need  to  stand 
upright,  fish  for  example,  need  very  much  less  skeleton ; 
we  need  a  great  deal  for  purposes  of  support.  Free- 
swimming  animals  do  not  need  so  much  stiffening. 

I  think  it  is  a  little  easier  to  begin  with  the  extremi- 
ties. The  human  arm  is  developed  out  of  the  fin  of  a 
fish.  As  we  come  up  the  animal  scale  through  such 
tools  as  wings,  paws,  or  legs,  we  have  one  bone  of  the 
original  fin  remaining  next  to  the  body;  that  joints  on 
to  two  bones,  which  in  turn  joint  on  to  a  number  of 
other  small  bones  (the  wrist  and  hand).  Thus,  from  a 
fin  you  get  an  arm ;  next  the  body,  one  bone,  then  two 
bones,  then  a  lot  of  little  bones  on  the  end.  That  ex- 
plains that  poor  arrangement  of  things  that  we  call  the 
wrist.  It  seems  a  stupid  arrangement,  a  mere  make- 
shift, but  perhaps  it  is  the  best  that  the  body  could  do 
in  making  an  arm  out  of  a  fin. 

The  same  idea  is  carried  out  in  the  lower  extremity: 
one  hip  bone,  two  lower-leg  bones,  a  lot  of  little  bones 
at  the  ankle,  and  then  toes.  It  looks  as  if  it  would  be 
much  better  to  have  one  bone  instead  of  all  this  mass 
of  little  bones  in  the  wrist  and  the  ankle.  If  we  have  to 
master  the  arrangement  of  those  bones,  we  soon  find 
out  how  arbitrary  and  awkward  it  is ;  but  as  a  way  of 
getting  for  ourselves  an  arm  and  hand  when  we  had  a 
fin  to  start  with,  it  becomes  on  the  whole  very  intelli- 
gent. Note,  then,  the  similarities  in  the  arm  and  leg, 
and  that  we  had  the  same  similarities  in  wing  and  claw 

3 


FIG.  i.    Leg  bones  of  various  animals  arranged  to  show  the  corresponding  parts. 
i.  Salamander.     2.  Frog.    3.  Turtle.     4.  Aetosaurus.     5.  Plesiosaurus.     6.  Ichthyosaurus. 
7.  Mpsosaurus.    8.  Duck.    In  each  leg  the  letter  /  stands  for  femur  or  thigh  bone,  "t  for  tibia 
or  shin  bone,  fi  for  fibula  the  other  bone  of  the  lower  leg.    The  toes  are  sometimes  numbered. 


/•# 


to,. 


"to*. 


FIG.  2.    More  leg  bones  arranged  as  in  Fig.  I. 


9.  Ornithorhynchus.  10.  Kangaroo,  n.  Megatherium.  12.  Armadillo.  13.  Mole.  14.  Sea 
lion.  is.  Gorilla.  16.  Man.  Note  how  in  the  kangaroo  and  sea  lion  the  thigh  bone  (/)  is 
abbreviated  in  comparison  with  its  size  in  man. 


ANATOMY  AND   PHYSIOLOGY 


and  finally  feet  :  one  bone  nearest  the  body,  then  two, 
then  many;  finally,  a  fanlike  extremity  which  can  either 
be  expanded  into  claws  or  fused  together  into  a  hoof, 
or  left  as  fingers  and  toes. 

The  four  extremities  are  fastened  to  the  trunk  by 
joints,  ligaments,  and  muscles;  the  upper  extremity 
extraordinarily  loosely,  the  lower  more  tightly.  The 


^   3.    To  S&CUr  luvr  ifc. 
CA          « 

Vurur 


arm  bone  fits  into  a  shallow  cup  in  the  shoulder  blade 
(the  scapula).  The  scapula  itself  is  attached  only  by 
muscles  to  the  collar  bone  and  to  the  chest.  The  whole 
thing  is  loose  and  free.  See  Fig.  3.  This  arrange- 

5 


ANATOMY  AND   PHYSIOLOGY 

ment  is  of  great  value  in  giving  extraordinarily  free 
motion  of  the  arm.  We  have  n't  anything  like  this 
motility  in  the  leg;  on  the  whole  we  do  not  need  it. 
The  leg  is  joined  on  much  more  firmly,  with  a  ball-and- 
socket  joint,  giving  greater  firmness  for  supporting 
the  body's  weight,  and  much  less  freedom  for  other 
purposes. 

The  rest  of  the  skeleton  is  essentially  the  backbone, 
skull,  thorax,  and  pelvis.  The  backbone  is  made  of 
a  number  of  separate  pieces,  vertebra,  which  come 
through  the  whole  vertebrate  kingdom  from  the  fish 
up.  We  often  find  on  the  beach  the  vertebrae  of  fish 
which  we  can  recognize  at  once  as  vertebrae.  They  are 
piled  on  top  of  each  other  like  bricks,  in  a  column, 
with  cartilage  binding  each  to  each  like  mortar.  The 
whole  column  is  hollow,  and  down  the  centre  of  it  goes 
a  prolongation  of  the  brain,  which  we  call  the  spinal 
cord,  through  which  travel  all  the  influences  of  com- 
mand which  pass  out  of  the  brain  and  all  the  news 
messages  which  come  into  the  brain.  The  branches 
of  spinal  cord  get  to  the  outer  world  through  a  series 
of  side  windows  which  perforate  the  vertebrae  every 
inch  or  so.  From  these  branches  come  pairs  of  nerves, 
right  and  left,  all  the  way  up  and  down  from  the 
level  of  the  skull  clear  down  to  the  pelvis.  Those 
nerves  branch  and  branch  like  trees  and  their  tips  go 
to  every  part  of  the  body:  to  the  face,  the  head,  the 
arms,  the  chest,  the  abdomen,  and  the  legs. 

The  rather  bizarre  arrangement  of  ribs  —  which 

7 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 


>- 


to* 


irreverent  medical  students  often  call  the  "bird-cage" 
—  is  a  compromise  between  a  defence  and  mobility.  The 
heart  and  lungs  are  indispensable  and  precious  organs 
which  must  be  protected  as  far  as  possible,  but  still 
must  have  free  motility  for  breathing.  The  ribs  serve 
these  two  purposes  admirably.  In  the  back  the  ribs  are 
hinged  on  the  backbone  (spinal  column)  so  that  when 
we  breathe  in  they  rise  and  go  upwards,  and  as  the  air 
goes  out  they  go  down  again  and  the  chest  becomes 
smaller. 

The  scapula^  or  shoulder  blade,  doubtless  serves 

8 


ANATOMY  AND   PHYSIOLOGY 


some  purpose  of  protection.  Otherwise  it  is  pretty  hard 
to  see  why  we  have  it.  In  birds  there  is  very  much  less 
of  it,  and  yet  the  muscles,  which  fasten  on  it,  are  car- 
ried just  as  well. 

The  pelvic  bones  are  thick  and  heavy  for  three  pur- 
poses: first,  to  protect  the  vulnerable  and  precious 

9 


A  LAYMAN'S  HANDBOOK  OF   MEDICINE 


genital  organs,  and  the  developing  baby  in  the  female; 
secondly,  because  the  back  and  leg  muscles,  the  largest 
and  strongest  muscles  in  the  body,  pull  upon  these 
bones;  and  thirdly,  because  through  them  the  whole 
body  weight  is  transmitted  to  the  legs.  The  outlet  of 
the  pelvis,  through  which  the  baby  has  to  pass  when 
it  is  born,  is  between  the  sacrum  (what  corresponds 
to  the  root  of  the  tail  of  our  arboreal  ancestors)  and  the 


tT 


GBT 


«utT 


pubic  bone  in  front. 
The  size  and  shape  of 
that  opening,  as  it  is 
made  right  or  wrong, 
roomy  or  narrow,  de- 
termine the  ease  or 
difficulty  of  childbirth. 
One  of  the  duties  of 
the  obstetrician  is  to 


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A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

measure  those  bones  before  childbirth  and  know  ex- 
actly whether  there  is  proper  room  for  a  child  to  pass 
between. 

The  Muscles 

Bones,  aside  from  stiffening  and  support,  serve  the 
purpose  of  giving  points  of  attachment  to  the  muscles. 
When  I  wish  to  draw  my  arm  up,  I  am  able  to  do  so 
because  the  muscle  which  is  attached  at  A  is  also  at- 
tached at  B.  When  that  muscle  contracts,  it  draws  the 
points  A  and  B  nearer  together  —  the  characteristic 
work  of  every  muscle  being  to  bring  its  two  ends  nearer 
together.  Because  a  muscle  can  do  that,  an  arm  can 
move.  Because  another  muscle  which  is  hitched  on  the 
back  of  the  upper  arm  and  on  the  back  of  the  forearm, 
because  that  muscle  also  contracts  and  pulls  up  the 
tip  of  the  elbow,  we  are  able  to  push  the  arm  out 
straight.  All  movements  that  we  make  —  such  as  the 
movements  of  the  tongue  and  face,  the  fine  movements 
of  the  hand,  of  the  trunk  and  legs  —  are  possible  be- 
cause the  two  ends  of  some  muscle  come  nearer  to- 
gether. Because  these  two  ends  are  fixed  to  bones  at 
the  extremity,  the  muscle  is  able  to  move  the  limb,  the 
trunk,  or  the  head. 

We  need  to  know  very  little  about  the  muscles  so 
far  as  I  see.  Physicians  also  know  very  little  about 
them.  They  occur  in  two  great  groups,  a  fact  that  one 
can  readily  remember :  a  group  that  bend  up  (flexors) , 
and  a  set  that  stretch  out  (extensors).  In  every  part 

12 


ANATOMY  AND   PHYSIOLOGY 

of  the  body  there  are  these  pairs  of  muscles  opposite 
to  each  other,  all  of  them,  of  course,  controlled  by 
nerves,  which  go  up  through  the  spinal  column  to  the 
brain.  Every  motion  starts  in  the  brain,  comes  out 
through  the  spinal  column  and  nerves  to  the  muscles, 
and  so  to  the  bones.  The  end  result  of  a  command 
coming  from  our  brain  is  to  move  a  bone.1 

There  is  also  a  small  group  of  muscles  called  involun- 
tary, not  subject  to  the  will,  muscles  which  contract 
without  our  control  or  intention.  The  best  examples 
are  the  muscles  of  the  heart  and  the  muscles  of  the  in- 
testine. Those  are  a  little  different  microscopically 
from  other  muscles.  They  are  not  attached  to  bones, 
and  they  get  their  pull  in  both  cases  from  the  fact  that 
they  are  circular.  The  heart  muscles  run  around  the 
heart,  the  intestine  muscles  around  the  intestine,  and 
when  they  shorten  they  shorten  all  around  the  circle, 
as  a  rubber  band  shortens  when  it  draws  in. 

Contents  of  the  Chest  and  Abdomen 

The  cavity  of  the  human  body,  when  we  leave  out 
of  account  the  extremities  and  the  head,  is  an  oval 
divided  into  an  upper  chamber  and  a  lower  chamber 
by  the  diaphragm,  which  is  the  floor  of  the  chest  cavity 
and  the  ceiling  of  the  abdominal  cavity.  The  dia- 
phragm is  an  arched,  smooth,  flat  muscle  hardly  any 
thicker  than  cardboard  in  parts.  Like  any  other 

1  Among  the  voluntary  muscles  there  are  but  a  few  unimportant 
exceptions  to  this  rule.  But  it  does  not  hold  for  the  group  next 
described. 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 


muscle,  it  can  contract.  It  is  hitched  to  the  ribs  on 
both  sides;  to  the  backbone  behind  and  to  the  breast- 
bone in  front.  When  it  contracts,  of  course,  it  must 
draw  its  ends  nearer  together.  To  do  that  it  must  "de- 
scend "  as  we  say  —  that  is,  flatten  out  its  arch.  When 
it  flattens  out,  its  centre  goes  down,  like  the  piston  of  a 
pump,  and  thus  sucks  air  into  the  chest  through  the 
mouth.  That  is  the  great  action  of  breathing,  far  more 
important  than  anything  the  ribs  do.  Even  when  the 
rib  joints  are  ossified  and  the  rib  rigidly  fixed  to  the 
spine,  the  person  breathes  fairly  well.  But  if  the  dia- 
phragm is  paralyzed,  the  person  dies.  It  is,  therefore, 
the  most  important  muscle  that  we  have.  It  divides 
the  body,  as  above  said,  into  two  great  cavities,  the 
chest  above  and  the  abdomen  below. 

14 


ANATOMY  AND   PHYSIOLOGY 


The  Heart  and  Lungs 

The  lungs  fill  nearly  all  the  upper  body  chamber  ex- 
cept what  is  filled  by  the  heart.  There  are  no  impor- 
tant organs  in  this  cavity  except  the  heart  and  lungs, 

(htelto&k** 


-Jt"  > 


ij|U»-   "\| 


All  the  rest  of  the  bothersome  organs  are  below  the 
diaphragm.  From  the  heart,  as  Figure  10  shows,  go 
two  great  branches,  the  beginning  of  the  arterial  tree, 

15 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

nearest  the  heart.  From  the  main  arterial  trunks  go 
the  larger  branches,  and  then  smaller  and  smaller 
twigs,  until  we  get  down  to  the  capillaries,  of  micro- 
scopic size.  They  honeycomb  the  tissues  themselves, 
and  regather  on  the  other  side  to  form  another  set  of 
tubes,  the  veins;  these  gather  into  large  tubes,  one 
leading  back  to  the  heart  from  above  and  one  coming 
from  below. 

It  is  not  worth  while  to  go  into  the  details  of  circula- 
tion. In  a  general  way  it  has  this  plan:  the  heart 
pumps  in  two  directions  at  once.  When  it  contracts, 
it  pushes  the  blood  out  as  we  squeeze  water  out  of  a 
sponge;  the  blood  goes  out  in  two  directions.  Through 
one  set  of  tubes  it  goes  to  the  lungs.  (The  lungs  are 
especially  favored ;  they  have  one  set  of  tubes  to  them- 
selves.) All  the  rest  of  the  body — the  heart,  brain,  liver, 
kidneys,  stomach,  intestine,  arms,  legs,  genitals  — 
has  another  set  of  tubes  branching  from  one  trunk 
(the  aorta).  From  both  of  these  regions  the  blood  re- 
turns and  starts  again.  On  its  way  out  we  call  it  arterial 
blood,  and  the  tubes  we  call  arteries.  On  its  way  back 
to  the  heart  we  call  it  venous  blood,  and  the  tubes  that 
carry  it  we  call  veins.  In  the  nerves,  brain,  muscles, 
and  every  part  and  organ  of  the  body  there  are  ex- 
traordinarily fine  tubes,  the  capillaries,  finer  than  any 
hair,  in  close  contact  with  every  part  of  every  organ. 
They  receive  from  the  arteries  nourishment  for  every 
tissue.  Downstream  from  the  capillaries  the  veins 
carry  back  the  venous  blood  containing  the  body  waste. 

16 


W  o{  Oroa*. 


Lv^ac,uwAAx«    cv^ 
<sThJ  axdj    ' 
* 


a»-a 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

The  great  function  of  circulation  is  to  warm  and 
nourish  the  body.  It  carries  the  air  and  food  to  the 
organs  and  it  carries  back,  away  from  the  organs,  some 
of  their  waste  products. 

Respiration 

The  lungs,  the  position  of  which  we  see  in  Figure  12, 
fill  up  all  the  space  in  the  chest  except  that  which  is 


taken  by  the  heart.  They  fill  all  the  chinks  around  the 
heart,  which  is  set  on  the  diaphragm  a  little  to  the  left. 
To  the  lungs  the  blood  is  sent  by  the  heart  after  re- 
turning from  all  the  rest  of  the  body,  bearing  the  waste 
products.  In  the  lungs  that  blood  meets  with  air,  the 
air  which  we  draw  into  our  lungs  with  each  breath. 

18 


ANATOMY  AND   PHYSIOLOGY 

If  we  ask  just  how  this  meeting  occurs,  it  is  hard  to 
answer.  It  is  a  very  mysterious  process,  for  the  oxygen 
of  the  air  goes  into  the  blood  right  through  the  walls  of 
the  blood  vessels.  But  parts  of  the  air  (what  the  body 
does  not  need)  are  left  behind.  It  is  not  at  all  a  process 
of  filtration ;  the  air  is  not  simply  sucked  in,  but  a  proc- 
ess of  intelligent  selection  goes  on.  The  air  contains 
some  things  which  the  body  needs  and  some  things 
that  it  does  not  need ;  in  the  blood  vessels  of  the  lungs 
it  meets  with  the  blood  which  contains  some  things  it 
does  not  need.  Then  an  exchange  occurs.  The  blood 
takes  about  twenty-three  per  cent  of  the  oxygen  out  of 
the  air  and  gives  back  in  exchange  another  gas  —  car- 
bon dioxide,  a  waste  product.  That  is  the  essential 
process  of  respiration. 

One  of  the  things  I  think  that  every  person  should 
know  about  respiration  and  the  lungs,  is  that  out  of  all 
the  oxygen  which  we  draw  into  our  lungs,  we  take  but  a 
small  part,  about  twenty-three  per  cent ;  we  reject  all  the 
rest.  In  other  words,  we  do  not  make  use  of  all  the 
oxygen  in  the  air  which  we  breathe  in,  because  the 
body  does  not  need  it.  The  practical  point  is  this: 
people  are  always  talking  about  getting  more  oxygen 
into  their  blood.  If  we  force  more  oxygen  into  our 
lungs,  we  do  just  the  same  thing  as  if  we  forced  upon  a 
man,  who  had  already  eaten  part  of  a  huge  dinner, 
six  more  dinners.  The  body  has  already  taken  all  it 
can  take  out  of  the  tremendous  superfluity  of  oxygen 
which  comes  into  the  lungs.  It  cannot  take  more. 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

Many  partially  educated  persons  think  that  if  we  take 
deep  breaths,  force  more  air  into  our  lungs,  we  shall 
get  more  oxygen  into  our  tissues.  But  we  cannot. 
There  is  no  sense  in  deep  breathing  for  the  purpose  of 
getting  more  oxygen  into  the  lungs.  It  has  an  effect 
upon  the  brain,  but  it  has  no  effect  upon  the  lungs;  it 
does  not  force  oxygen  into  the  system.  The  effect  upon 
the  brain  is  very  interesting:  it  puts  the  soft  pedal  on 
our  thoughts.  It  fogs  our  brains  which  is  sometimes  a 
good  thing  to  do.  For  that  reason,  among  Oriental  re- 
ligious sects  and  other  people  who  try  to  follow  their 
lines  of  thought,  the  practice  of  deep  breathing  persists, 
and  may  be  useful  because  of  its  calming  effect  upon 
the  brain.  Again,  deep  breathing  has  an  effect  upon 
the  bowels ;  I  think  it  is  of  use  in  some  cases  of  consti- 
pation, because  deep  breathing,  forcing  the  diaphragm 
down,  stirs  up  the  bowels  when  they  are  logy,  and 
helps  to  push  their  contents  along. 

Questions  and  Answers 

Q.  In  a  room  with  the  air  in  motion,  is  there  danger  from 
a  draught? 

A.  I  imagine  that  people  are  individual  in  that  matter. 
From  my  own  observation  I  should  say  that  most  of  us 
were  far  better  for  living  in  a  draught  all  our  lives,  but  that 
some  people  are  harmed  by  it. 

Q.  If  the  air  does  not  have  to  be  cold,  simply  has  to  be 
pure  and  to  be  in  motion,  what  is  the  advantage  of  an  out- 
door school? 

A.  Pure  air  means  air  that  is  not  too  hot  and  that  is 
in  motion.  These  conditions  are  easiest  found  outdoors. 

20 


ANATOMY  AND   PHYSIOLOGY 

Purity  has  nothing  to  do  with  CO2  or  O2.  Stale  air  may  be 
made  perfectly  fresh,  not  by  changing  the  oxygen,  but 
simply  by  cooling  and  putting  the  air  in  motion.  Indoors 
air  gets  hot  and  stagnant.  Outdoors  it  is  cooler  and  moves 
more.  I  am  leaving  out  here  the  question  of  odors,  which 
of  course  are  easier  lost  outdoors  than  in. 

The  Breathing  Tubes 

The  pharynx  is  the  back  of  the  throat.  There  we 
find  two  openings  going  down,  one  to  the  stomach,  the 
other  to  the  lungs.  When  we  say  that  a  child  swallows 
something  "the  wrong  way,"  we  mean  that  food  which 
was  meant  to  go  to  the  stomach  has  started  to  go  to  the 
lungs  by  mistake,  although  it  almost  never  gets  there. 
The  pharynx  is  the  common  beginning  of  these  two 
tubes,  one  that  goes  to  the  lungs  (the  windpipe  or 
trachea),  and  one  that  goes  to  the  stomach  (the  gullet). 
Upon  this  last  the  term  esophagus  has  such  a  firm  hold 
that  we  must  learn  it,  though  the  simple  word  gullet 
is  more  familiar. 

As  we  go  down  the  windpipe  leading  to  the  lungs, 
we  come  across  the  larynx.  Essentially  it  is  like  a 
stringed  instrument.  Any  stringed  instrument  makes 
music  because  a  cord  is  stretched  tight  and  vibrates. 
Two  cords,  the  vocal  cords,  are  stretched  tight  and 
vibrate  when  the  breath  from  the  lungs  goes  over  them. 
These  cords  make  what  is  essentially  a  little  musical 
instrument  set  in  the  tube  leading  to  the  lungs.  The 
air  coming  out  of  the  lungs  causes  the  vibrations  that 
make  our  voices,  whether  for  speech  or  song. 

21 


left  out. 

When  w<  Swallow,  tKe  tenant    &ti4cs   Her(tont«.U 
t»A4,K«<f ards.^see — *j[  an«l  skuts  tKc  tp»jtottJs 
over  tK<  mo«»tk  o|  tKc    urin4p«pe    so  a  %  to    keep 
««t  food 

€xcep1"  tKt  Windpipe   tk«  or)u>U  U  4r*«va   in 
<roii    stctt*n. 


ANATOMY  AND   PHYSIOLOGY 

Just  below  the  larynx  is  the  common  trunk  tube 
which  then  divides  into  right  and  left  branches.  The 
trunk  tube  is  the  trachea,  and  the  two  main  branches 


are  the  largest-sized  bronchi.  These  again  divide  and 
divide  repeatedly  into  smaller  tubes  (the  bronchioles), 
each  of  which  at  last  reaches  a  blind  poifth  lined  with 
blood  vessels  where  the  air  and  the  blood  meet  and 
barter  their  contents  in  the  extraordinary  way  that  I 
have  suggested,  the  blood  vessels  winding  in  and  out 
of  the  walls  of  the  end-pouches  so  as  to  get  at  the  air. 
These  pouches,  plus  the  tubes  leading  to  them,  plus 
the  blood  vessels,  plus  the  necessary  framework  to  hold 
them  all  together,  make  up  the  whole  lung.  Corre- 
sponding to  these  parts  we  use  many  different  terms : 
-  pharynx,  larynx,  trachea,  bronchi,  bronchioles, 
alveoli  (or  pouches),  which  simply  name  the  succes- 
sive parts  as  we  go  down  from  the  mouth. 

23 


C/hJut  €sl * 

fl&i 


ANATOMY  AND   PHYSIOLOGY 

The  Tonsils 

Just  above  the  pharynx,  at  the  root  of  the  tongue, 
are  the  tonsils.  The  tonsils  are  organs  the  use  of  which 


we  do  not  know.  People  in  whom  they  "have  been  re- 
moved do  just  as  well,  usually  better.  Like  the  spleen, 
they  represent  mysteries.  But  they  are  a  particular 
bother  to  us  because  so  many  of  the  dangerous  infec- 
tions spreading  to  the  heart  and  kidneys  seem  to  start 
in  them.  I  do  not  think  we  know  whether  those  ton- 
sil infections  go  in  or  come  out.  We  generally  assume 
that  they  go  in  to  the  tonsil  with  milk  or  whatever  is 
swallowed.  We  do  know  that  trouble  in  the  tonsils 
often  appears  just  before  some  more  serious  disease  of 
the  heart,  kidney  or  joints.  If  disease  starts  in  the  ton- 
sils, we  have  hope  for  the  future.  For  we  never  shall 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 


cure  heart  disease  or  kidney  disease,  but  we  may  pre- 
vent them  if  we  can  prevent  the  tonsillar  disease  from 
which  they  often  seem  to  start. 

The  Digestive  Tract 

The  digestive  tract  begins  in  the  mouth,  goes  on 
with  the  gullet,  which  pierces  the  diaphragm,  far  back 
against  the  backbone.  As  soon  as  it  gets  below  the 


lo 


diaphragm,  it  becomes  the  beginning  of  the  stomach. 
The  stomach  is  simply  an  enlargement  of  the  digestive 
tube  (gullet  above,  intestine  below)  which  leads  con- 

26 


ANATOMY  AND   PHYSIOLOGY 


tinuously  through  the  body,  from  the  mouth  to  the 
anus,  without  any  break;  so  that  a  substance  may  go 
into  that  tube  and  pass 
through  without  being  in 
the  body  in  any  other 
sense.  It  may  be  kept  out 
of  all  the  rest  of  the  body, 
enclosed  within  this  closed 
system  of  tubes.  This  is 
important.  Many  sub- 
stances, which  if  intro- 
duced into  the  blood  or 
muscles  would  kill,  are 
perfectly  harmless  within 
this  inner  protected  tube, 
the  digestive  tube.  Poison  meets  with  the  acids  and 
other  hostile  substances  there.  Some,  snake  poison,  for 
example,  is  harmless  in  the  stomach,  fatal  in  the  blood. 

•SJMS" 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

Just  below  the  stomach  we  have  this  double  turn 
called  the  duodenum,  which  is  simply  the  first  part  of 
the  intestine.  Below  this  we  have  about  twenty-two 


feet  of  tubing  (intestine)  which  fills  up  most  of  the 
space,  from  the  ceiling  or  diaphragm  above  to  the  pelvic 
floor  below.  That  twenty-two  feet  of  intestine  has  no 
fixed  dwelling-place;  it  shifts  and  squirms  and  fills  in 
chinks,  taking  now  this  position  and  now  that.  It  does 
not  stay  in  one  place  like  the  heart  and  lungs. 

After  the  twenty-two  feet  of  small-sized  intestinal 
tube,  we  come  to  a  portion  about  three  feet  long  called 
the  large  intestine,  about  twice  the  diameter  of  the  small 
intestine,  and  with  a  fairly  fixed  position.  The  large 
intestine  begins  at  the  place  which  most  people  are 
now  familiar  with,  as  the  home  of  the  appendix,  then 

28 


ANATOMY  AND   PHYSIOLOGY 

travels  up  to  the  left  ribs,  across  the  pit  of  the  stomach, 
then  down  and  out  through  the  pelvis.  The  use  of 
those  different  parts  I  have  now  to  recall. 


The  stomach  is  primarily  a  reservoir  and  a  mixer. 
It  is  not  nearly  as  important  an  organ  of  digestion  as 

29 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

the  small  intestine  is.  Its  chief  importance  is  mechani- 
cal, not  chemical;  not  mainly  to  change  the  food,  but 
to  mix  it,  to  hold  it  and  pay  it  out  a  little  at  a  time  into 
the  intestine  in  the  way  and  at  the  rate  that  the  in- 
testine can  take  it  best.  While  holding  food  it  changes 
and  mixes  it,  reducing  the  coarser  parts  to  soft  mate- 
rial. Some  chemical  change  also  goes  on  there,  but  that 
chemical  change  is  not  essential,  as  shown  by  the  fact 
that  if  the  whole  stomach  be  taken  out  and  the  lower 
end  of  the  gullet  hitched  to  the  upper  end  of  the  in- 
testine, all  necessary  digestion  of  the  food  can  be  per- 
formed in  the  gut.  In  fact  all  the  digestive  processes 
are  normally  performed  in  the  gut,  even  if  the  stom- 
ach does  them  first. 

Of  the  three  classes  of  foods  which  we  take  into  our 
body,  the  stomach  deals  to  some  extent  with  the  di- 
gestion of  one,  the  proteids,  and  practically  not  at  all 
with  the  other  two.  Meat,  milk,  eggs,  and  the  proteids 
of  vegetables,  the  stomach  deals  with,  breaks  them  up, 
adapts  them  to  some  extent  to  the  needs  of  the  body. 
It  has  for  that  purpose  an  acid  —  hydrochloric  —  and 
a  ferment  —  pepsin.  A  ferment  is  too  complicated  for 
me  to  describe,  something  which  acts  on  food  and  di- 
gests it,  without  itself  getting  into  the  food.  When 
hydrochloric  acid  acts  on  proteid,  it  forms  a  new  chemi- 
cal unit  with  the  proteid ;  the  ferment  does  not.  The 
food  thus  partially  digested  is  passed  on  to  the  duo- 
denum and  there  meets  the  bile  sent  down  by  a  special 
pipe  from  the  liver.  But  it  is  not  until  we  get  to  the 

30 


ANATOMY  AND   PHYSIOLOGY 

twenty-two  feet  of  intestine  that  food  is  digested  in  any 
essential  sense,  by  the  pancreatic  juice  and  bile  poured 
out  in  the  duodenum.  We  have  the  small  intestine  in 
order  that  the  food  may  be  spread  out  over  the  enor- 
mous surface  of  the  whole  twenty-two  feet  and  there 
digested  before  it  is  gradually  absorbed  into  the  blood. 
Before  food  is  absorbed  it  is  acted  on  in  the  small 
intestine  by  the  juice  of  the  pancreas.  The  pancreas 
is  by  far  the  most  important  organ  of  digestion,  and 
can  do  all  the  work  without  any  help  from  the  stomach 
itself.  The  pancreas  lies  close  behind  the  stomach,  a 
soft  grey  mass  about  the  size  and  shape  of  a  pistol 
shooting  to  the  left.  A  tube  leads  from  the  pancreas 
into  the  duodenum,  and  through  that  tube  goes  the 
powerful  digestive  juice  without  which  the  body  can- 
not live.  If  that  duct  gets  stopped  up  or  cut,  the  person 
soon  dies.  Absolutely  essential  is  that  pancreatic  juice. 
^  I.  The  stomach  is  for  storing  and  mixing. 
•L"  2.  The  intestine  is  for  digestion  and  absorption. 

3.  The    pancreas   supplies   the    essential    chemical 
which  changes  the  food  into  something  the  body  can 
use. 

4.  The  stomach  juices,  the  bile,  and  the  juice  of  the 
intestine  itself,  are  minor  factors  in  digestion. 

At  the  beginning  of  the  large  intestine  the  food  res- 
idue slows  up  and  begins  to  accumulate  as  the  watery 
part  of  it  is  absorbed,  so  that  instead  of  being  of  the 
consistency  of  thick  soup,  as  it  is  all  through  the  small 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

intestine,  it  becomes  more  and  more  dry  and  finally  of 
the  consistency  of  the  feces  discharged  in  the  form  of  a 
"  movement  of  the  bowels."  Feces  represent  the  waste 
product  of  the  food,  what  we  do  not  need  and  cannot 
use.  They  also  represent  a  good  deal  of  substance 
secreted  by  the  bowel  itself.  A  person  taking  no  food 
at  all  will  have  movements  of  the  bowels,  consisting 
mostly  of  a  substance  secreted  by  the  intestine  out  of 
its  own  wall. 

At  the  very  beginning  of  the  large  intestine,  on  the 
right  side  near  the  hip  bone,  is  the  part  that  every- 
body knows  about,  the  appendix,  one  of  the  disastrous 
mistakes  of  human  anatomy,  which  was  of  value  to 
some  of  the  lower  animals,  but  to  us  has  no  value  and 
great  dangers.  The  appendix  is  a  pouch  about  as  big  as 
the  little  finger  of  a  glove;  it  hangs  down  like  a  tail  free 
from  the  intestine.  It  communicates  directly  with  the 
intestine,  but  is  very  prone  to  get  stopped  up,  to  get 
inflamed,  and  when  inflamed  to  produce  a  dangerous 
peritonitis.  Peritonitis  is  the  inflammation  of  the  lining 
membrane  of  the  abdomen,  the  walls  which  shut  in 
the  intestine  as  I  have  described  it. 

Questions  and  Answers 

Q.  Why  does  blood  go  back  to  the  heart? 

A.  It  is  pushed  on  from  behind  and  sucked  from  in  front. 
The  system  of  tubes  is  closed.  There  is  nowhere  else  it  can 
go.  Moreover,  in  the  veins  there  are  valves  which  open  to- 
ward the  heart  and  close  the  other  way,  so  that  any  blood 
that  gets  going  is  held  by  them.  Second,  the  veins  go  in 

32 


ANATOMY  AND   PHYSIOLOGY 

among  the  muscles.  Every  time  the  muscles  contract  they 
squeeze  the  veins.  The  veins  are  so  thin-walled  that  they  con- 
tract, are  thus  emptied,  and  because  of  the  valves  they 
must  empty  toward  the  heart. 

Q.  How  does  it  get  from  the  arteries  to  the  veins? 

A.  Through  the  capillaries.  The  capillaries  are  a  closed 
system  of  tubes,  very  small,  continuous  from  the  arteries  on 
one  side  to  the  veins  on  the  other. 

Q.  I  did  n't  understand  what  you  said  about  deep  breath- 
ing. 

A.  I  said  that  taking  deep  breaths,  so  as  to  force  air  into 
the  lungs,  did  not  force  any  more  oxygen  into  the  blood, 
and  did  not  therefore  accomplish  what  it  is  supposed  to  ac- 
complish. In  the  lungs  our  blood  selects  out  of  the  total 
bulk  of  oxygen  that  comes  there  a  small  proportion,  about 
twenty-three  per  cent  which  we  use;  the  rest  we  reject.  If 
we  face  a  draught  or  try  to  get  any  more  air  into  the  lungs, 
we  do  not  get  any  more  oxygen.  Fresh  air,  aside  from  its 
freedom  from  smells,  means  essentially  two  things:  air  that 
is  not  too  hot  and  air  that  is  in  motion.  If  we  get  into  a 
room  where  the  air  is  stale  and  close,  we  can  make  that  air 
fresh  by  cooling  it  and  setting  it  in  motion.  We  do  not  need 
any  more  oxygen  nor  any  less  carbon  dioxide. 

The  reason  that  motion  is  necessary  to  freshen  air  is  this : 
The  body  warms  a  little  coating  of  air  around  itself,  and  that 
envelope  of  air  is  not  easily  broken  up  unless  the  air  around  us 
is  in  motion.  Without  motion  breaking  up  our  warm  air  en- 
velopes, the  cool  air  does  not  really  get  to  us;  it  is  held  off  by 
the  envelope  of  heat  around  us.  The  value  of  deep  breathing 
is  for  the  mind  and  for  the  bowels.  Do  not  discourage  any- 
body from  it,  but  only  from  thinking  that  it  will  do  any  good 
to  their  lungs. 

Q.  Would  it  not  increase  the  circulation  of  air  in  the  upper 
lobes  of  the  lungs? 

A.  Possibly ;  but  no  one  knows  whether  there  is  any  value 
in  that. 

33 


A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

Q.  Would  it  help  to  develop  the  muscles  of  the  chest? 

A.  Yes,  but  that  is  not  important. 

Q.  Is  the  fellow  with  a  sunken  chest  just  as  well  off  as  the 
one  who  stands  straight? 

A.  The  fellow  with  a  sunken  chest  is  not  as  good  an  asset. 
It  is  not  so  much  a  hygienic  question  as  an  aesthetic  and 
financial  question.  The  man  who  stands  straight  presents  a 
more  beautiful  picture  to  the  eye  and  can  get  a  better  job. 

Q.  Does  not  a  sunken  chest  cramp  the  lungs  and  so  in- 
jure them? 

A.  I  know  no  evidence  of  that.  Moreover,  large  lungs 
are  not  an  advantage  so  far  as  I  know.  I  wholly  believe  in 
standing  up  straight,  but  not  for  hygienic  reasons.  I  believe 
in  it  for  moral,  financial,  and  aesthetic  reasons. 

The  Liver 

The  liver  is  the  largest  organ  of  the  body,  and  with 
one  or  two  exceptions,  the  least  understood.  We  really 
do  not  know  why  we  have  such  an  amount  of  liver.  It 
fits  snugly  under  the  right  dome  of  the  diaphragm  and 
goes  clear  across  the  body  from  side  to  side.  We  know 
from  our  experience  at  the  dinner  table  what  its  con- 
sistency is.  It  was  once  taught  in  physiology  that  the 
purpose  of  the  liver  is  to  secrete  bile,  and  that  it  cer- 
tainly does,  but  that  is  a  relatively  slight  and  unim- 
portant function.  A  more  important  thing  that  the 
liver  does,  in  all  probability,  is  to  stop  poisons,  formed 
in  the  intestine  during  the  digestion  of  food,  from  get- 
ting into  the  general  circulation.  The  blood  goes  from 
the  intestine  through  the  liver  before  it  joins  the  gen- 
eral blood  stream  on  its  way  back  to  the  heart.  It  is 
hard  to  realize  that  strong  poisons  are  made  three 

34 


ANATOMY  AND   PHYSIOLOGY 

times  a  day  in  the  process  of  breaking  up  our  food. 
When  our  food  is  in  the  intermediate  stages,  between 
its  unchanged  state  and  its  final  condition  as  part  of 
our  bodies,  it  is  sometimes  very  poisonous.  We  be- 
lieve that  those  poisons  are  neutralized  or  put  out  of 
action  in  the  liver. 

The  liver  is  sometimes  a  storehouse  of  fat.  There  are 
certain  reservoirs  in  the  body  where  fat  is  stored.  One 
of  them  is  the  abdominal  wall,  where  people  try  to  con- 
ceal it  by  wearing  tight  corsets.  Another  one  is  round 
the  kidney,  where  great  masses  of  fat  collect.  And 
another  one  is  in  the  liver  itself.  More  important  is 
glycogen,  one  of  the  intermediate  products  of  starch 
and  sugar  digestion,  which  is  accumulated  and  stored 
in  the  liver.  When  a  man  is  starving  to  death  he  lives 
for  a  considerable  time  on  his  own  liver,  his  storehouse 
of  fat  and  sugar. 

The  liver,  then,  as  a  detoxicator  (unpoisoner)  and 
as  a  storehouse  of  sugar  and  fat  is  an  important  organ  ^ 
Its  function  as  a  secreter  of  bile  is  much  less  impor- 
tant. We  can  remove  a  considerable  portion  of  the 
liver  without  a  person  suffering.  When  we  get  down 
to  about  two  fifths  and  have  removed  three  fifths  he 
begins  to  feel  it ;  but  we  have  apparently  a  great  deal 
more  liver  than  we  need  for  the  preservation  of  life. 

The  left  end  of  the  liver  touches  the  spleen  at  the 
bottom  of  the  ribs,  above  the  left  hip.  The  use  of  the 
spleen  we  do  not  know :  take  it  out  and  the  human  be- 
ing gets  on  just  as  well.  It  certainly  is  not  important 

35 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

to  life.  It  serves  certain  purposes,  such  as  that  of  a 
graveyard  for  superannuated  red  corpuscles.  That  is 
one  of  the  places  where  red  corpuscles  go  when  they  die. 
But  when  you  remove  that  graveyard  the  body  seems 
to  get  along  just  as  well.  We  do  often  remove  it  now- 
adays, and  no  harm  results.  But  we  could  not  remove 
the  kidneys,  the  liver,  pancreas,  or  any  other  organ 
named  thus  far  or  the  patient  would  die. 

The  Urinary  Organs 

Half  of  each  kidney  is  above  the  lowest  rib  in  the 
back  and  half  is  below.  They  are  bean-shaped  and 
stand  perpendicularly  with  the  twelfth  rib  going  nearly 
across  the  middle.  They  are  close  below  the  dia- 
phragm and  just  outside  the  spinal  column.  One  of 
the  most  interesting  facts  about  the  kidneys  is  the 
extraordinary  mass  of  blood  that  goes  through  them. 
All  the  blood  in  the  body  goes  through  the  kidneys 
within  a  few  minutes.  The  size  of  the  artery  going  to 
the  kidney,  compared  to  the  size  of  the  kidney  itself, 
is  enormous,  and  the  importance  of  that  is  obvious 
when  we  see  that  the  kidney  has  to  take  out  of  the 
blood  most  of  the  waste  substances  accumulated  there. 
The  blood  circulates  through  the  kidney,  and  by  some 
mysterious  process  the  kidney  selects  what  ought  to 
come  out  of  the  blood  and  takes  it  out ;  the  blood  then 
flows  on  and  back,  back  toward  the  heart  through  the 
kidney  vein.  Those  substances  which  the  kidney  takes 
out  of  the  blood  constitute  the  urine.  Running  down 

36 


ANATOMY  AND   PHYSIOLOGY 

and  in  from  the  parts  near  the  surface  of  the  kidney 
where  subtraction  is  made,  the  urine  accumulates  in 
little  tubes  which  radiate  toward  the  inner  curved 
centre  of  the  kidney,  what  is  called  the  pelvis  of  the  kid- 
ney, and  there  is  gathered  up  into  one  main  tube,  the 
ureter.  There  is  a  ureter  on  each  side,  a  tube  as  big  as 


the  little  finger,  or  a  little  smaller,  which  runs  from  the 
kidney  round  to  the  front  and  down  into  the  bladder. 
The  bladder  fits  in  behind  the  pubic  bone.  Low  down 
and  at  the  back  of  the  bladder  enter  the  two  ureters 
coming  down,  one  from  each  kidney.  This  bladder 

37 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

serves  as  a  reservoir  for  urine  until  it  is  ready  to  be  dis- 
charged. The  ureter  is  the  tube  leading  from  the  kidney 

to  the  bladder.  The 
urethra  is  the  shorter 
tube  leading  from  the 
bladder  to  the  world 
outside  the  body. 

The  Genital  Organs 

Female  Genitals.  Be- 
hind the  front  part  of 
the  pelvic  cradle,  which 
comes  round  from  the 
backbone  to  the  front, 
is  the  uterus,  a  hol- 
low muscle,  pear-sized, 
pear-shaped,  and  open 
below.  From  each  side 
of  it  goes  off  the  Fallo- 
pian tube,  which  is  ordinarily  spoken  of  as  "the  tube/' 
When  doctors  speak  of  "the  tube"  and  nothing  more, 
it  generally  means  the  Fallopian  tube.  When  we  hear 
that  a  woman  has  "the  tubes  and  ovaries  removed," 
it  means  the  Fallopian  tubes.  The  tube  ends  in  a 
group  of  delicate,  threadlike  extremities  that  do  not 
directly  enter  the  ovary,  which  is  suspended  in  the 
pelvis  by  another  set  of  ligaments,  close  to  the  end 
of  the  tube.  One  of  the  extraordinary  things  about 
this  arrangement  is  that  there  is  no  direct  connection 

38 


ANATOMY  AND   PHYSIOLOGY 


between  the  ovary  and  the  tube.    The  importance  of 
that  I  will  speak  of  a  little  later. 

The  uterus  projects  into  the  vagina,  which  is  the 
tube  leading  to  the  external  world.  The  uterus,  tubes, 
ovaries,  and  vagina  make  up  the  essentials  of  the  fe- 


7^-  ^ 


. 


IK 


male  genital  system.  When  the  spermatozoon  (the 
male  seed)  enters  the.  vagina,  it  travels  up  the  uterus 
and  along  the  Fallopian  tube.  One  would  naturally 

39 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

think  that  the  female  seed  coming  from  the  ovary 
would  also  have  an  opportunity  to  get  directly  into  the 
Fallopian  tube  and  so  into  the  uterus,  but  it  does  not. 
Usually  it  gets  across  the  space  between  the  ovary  and 
the  tasselled  end  of  the  tube.  But  it  may  fall  loose  in 
the  abdominal  cavity. 

When  the  spermatozoon  meets  the  ovum,  which  has 
somehow  got  into  the  Fallopian  tube,  the  two  unite  and 


Q 


form  one  cell  in  this  tube.  They  then  make  their  way 
down  the  tube  to  the  uterus  and  are  implanted  in  the 
wall  of  the  uterus,  taking  root  there  as  a  tree  takes 
root  in  soil.  That  is  normal  pregnancy.  After  that  the 
fertilized  ovum  —  that  is  the  egg,  the  female  element 
joined  with  the  male  element  —  increases  in  size,  be- 
cause its  cells  divide  and  divide  to  form  new  cells,  and 
gradually  forms  the  embryo  of  the  human  being.  As 

40 


ANATOMY  AND   PHYSIOLOGY 

that  enlarges,  the  uterus  enlarges  to  hold  it.  This  is 
again  one  of  the  most  mysterious  processes  —  how  the 
uterus  knows  enough  to  change  from  this  small  hol- 
low muscle  into  the  huge  sac  big  enough  to  hold  the 
child  before  birth.  It  undergoes  all  these  changes  in  re- 
sponse to  the  need  for  them,  and  that  is  all  we  can  say 
about  it. 

I  have  described  normal  pregnancy.  Sometimes 
the  ovum,  after  joining  the  spermatozoon,  takes  root 
in  the  tube.  That  is  tubal  pregnancy  which  ends  by 
rupture  of  the  tube,  often  with  serious  hemorrhage. 

I  have  given  so  far  no  account  of  the  relation  of  the 
uterus  to  the  bladder,  and  that  is  much  better  brought 
out  by  a  side  view  (Fig.  25).  In  front  is  the  pubic  bone, 
the  front  of  the  pelvic  cradle,  and  just  back  of  it  is  the 
bladder.  The  uterus  is  right  behind  that,  an  inch  or 
two  back  from  the  pubic  bone,  and  its  position  varies 
in  different  people  and^in  the  same  person  at  different 
times.  There  is  no  one  right  position  of  the  uterus.  We 
used  to  teach  that  it  ought  to  be  slung  forward  and 
upright,  and  that  if  it  was  not  in  that  position  it  was 
not  right.  But  in  fact  it  may  tip  forward,  it  may  be 
straight  up  and  down,  or  it  may  be  turned  clear  back, 
and  yet  be  perfectly  normal.  Disease  results  only  when 
the  uterus  gets  tied  down  as  a  result  of  inflamma- 
tion and  cannot  move.  Scars  which  form  around  the 
uterus  fix  the  organ  in  a  single  position  and  give  rise  to 
pain,  constipation,  and  disturbance  of  menstruation. 
If  there  are  no  scars  and  the  uterus  can  move  freely, 


A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

its  position  is  not  important.  We  are  constantly  hear- 
ing of  women  who  have  retroversions  of  the  uterus  or 
some  other  supposed  malposition.  But  the  best  knowl- 
edge of  to-day  recognizes  no  single  right  position  of  the 
uterus.  In  the  majority  of  people  the  uterus  lies  tipped 
slightly  forward  over  the  bladder. 

The  bladder  has  its  own  tube  to  the  outer  world, 
the  urethra,  which  is  just  above  the  vagina,  which  itself 
is  just  above  the  anus,  the  opening  of  the  digestive 
tube.  It  is  because  of  this  close  position  to  the  uterus 
that  enlargements  of  the  uterus  often  trouble  the  blad- 
der, and  make  the  urine  pass  frequently  and  with 
difficulty. 

Just  behind  the  uterus  itself  comes  the  rectum,  the 
lowest  piece  of  the  large  intestine,  which  empties  at 
the  anus,  just  below  the  vagina.  In  the  passage  of 
the  child  out  of  the  genital  canal,  the  vaginal  canal 
enlarges  extraordinarily  to  let^the  head  of  the  child 
through,  but  in  spite  of  that  enlargement  there  is  apt 
to  be  some  laceration  both  of  the  neck  of  the  womb  and 
of  the  external  outlet,  and  we  often  hear  that  such  and 
such  a  woman  must  have  a  "  cervix-and-perineum " 
operation.  The  cervix  is  the  outlet  at  the  lower  end  of 
the  womb,  and  the  perineum  is  at  the  lower  and  poste- 
rior edge  of  the  vaginal  tube.  One  of  these  is  veVy 
often  torn  and  needs  repair.  That  repair  is  always  a 
minor  matter,  is  never  essential  to  life,  and  seldom  to 
health. 

Male  Genitals.  In  the  testicle,  the  spermatozoa 

42 


ANATOMY  AND   PHYSIOLOGY 

(the  male  seed)  are  formed  in  millions.  From  there 
they  go  up  through  the  spermatic  cord,  which  passes 
through  the  groin,  then  doubles  back  upon  itself  be- 
hind the  bladder  and  goes  to  the  region  of  the  prostate 
gland,  which  is  behind  the  pubic  bone  and  surrounding 
the  first  part  of  the  male  urethra.  This  tube,  which 
leads  to  the  external  world,  passes  through  the  prostate 
gland  which  surrounds  it  as  a  lemon  might  surround  a 
tube  pushed  through  it.  The  male  seed  passes  out  to 
the  external  world  from  the  same  tube  as  the  urine. 


a    17    Gloss 

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A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

One  of  the  important  points  in  relation  to  the  sper- 
matic cord  is  that,  as  it  leaves  the  testicle,  it  passes 
very  close  beneath  the  skin,  so  that  by  a  very  slight 
operation  it  can  be  cut  and  the  individual  thus  ren- 
dered sterile.  The  operation  has  been  done  a  great 
many  times,  whether  justifiably  or  not,  in  the  case  of 
criminals.  It  is  only  a  slight  operation,  done  in  a  few 
minutes  under  local  anaesthesia. 

We  have  then  three  separate  organs:  (a)  The  blad- 
der with  the  ureters  coming  from  above,  and  the  urethra 
emptying  below  through  the  penis,  (b)  The  prostate 
gland  —  the  use  of  which  nobody  knows,  and  the  dis- 
advantages of  which  are  enormous.  And  (c)  the  genital 
tubes  coming  up  from  the  testicle  and  discharging  into 
the  urethra,  just  after  it  leaves  the  bladder. 

As  I  have  said,  nobody  knows  the  use  of  the  pros- 
tate gland.  In  the  majority  of  elderly  men  it  enlarges 
and  often  obstructs  the  orifice  of  the  bladder  so  that 
the  urine  cannot  get  out.  The  bladder  then  does  not 
empty  itself  and  becomes  distended.  Hence  come  the 
urinary  troubles  of  old  men,  from  which  women  fortu- 
nately are  exempt. 

The  spermatozoa,  formed  in  the  testicle  in  millions, 
accumulate  in  a  little  reservoir  just  above  the  prostate 
gland,  and  from  time  to  time  in  healthy,  chaste  males 
this  reservoir  overflows  and  is  emptied  out  in  sleep, 
the  so-called  "nocturnal  emission/'  which  is  perfectly 
normal,  but  often  leads  young  men  to  suppose  that 
they  are  diseased  and  to  get  into  a  very  miserable, 

44 


ANATOMY  AND   PHYSIOLOGY 

brooding,  melancholic  state.  This  possibility  is  seized 
upon  by  quacks  who  tell  them  that  emissions  mean  dis- 
ease and  that  they  can  cure  it.  Sometimes  much  money 
is  thus  wasted  and  much  unhappiness  results. 

When  the  prostate  gland  obstructs  urinary  outflow, 
it  can  be  removed,  wholly  or  in  part,  and  this  is  a  very 
common  operation,  though  it  has  some  dangers  because 
of  the  weakened  condition  in  which  the  man  often  is. 
However,  it  is  a  very  important  operation,  done  in- 
numerable times  in  every  great  hospital.  The  relief 
from  a  skilful  operation  is  very  great. 

Questions  and  Answers 

Q.  Are  the  uterus,  etc.,  contained  in  a  sac? 

A.  They  are  held  up  by  bands  of  fibrous  connective  tissue, 
but  not  joined  together.  It  is  one  of  the  vast  mysteries  that 
they  are  not  joined  together,  but  separate  so  that  the  ovum 
can  get  lost.  They  are  not  joined  to  any  other  organ. 

Q.  What  happens  when  the  ovum  gets  lost? 

A.  If  the  ovum  is  fertilized  and  drops  into  the  belly  cavity, 
the  individual  is  supposed  to  have  an  abdominal  tumor. 
Operation  reveals  the  presence  of  the  fetus  developing  free 
in  the  abdominal  cavities.  It  is  one  of  those  blunders  which  I 
referred  to  which  cannot  be  explained  except  by  saying  that 
the  human  body  is  trying  hard  to  do  a  difficult  thing,  and  is 
doing  the  best  it  knows  how. 

The  Nervous  System 

The  brain,  the  spinal  cord,  and  the  nerve  fibres  run- 
ning from  it  to  the  muscles  and  organs  of  the  body,  are 
the  most  important  parts  of  the  nervous  system  for  an 
audience  such  as  this  book  means  to  reach.  The  brain 

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A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

occupies  the  dome  of  the  skull  above  a  horizontal  line 
drawn  from  the  eyebrows  to  the  back  of  the  head.  Its 
hindmost  and  lowest  portion  is  prolonged  into  a  tail 
like  a  Chinaman's  queue,  and  this  tail  (the  "  spinal 
cord")  runs  down  inside  the  bony  column  of  the  spine. 
Between  each  two  stones  of  this  column  (or  between 
each  two  vertebrae)  are  windows  (see  Fig.  5,  p.  8) 
—  through  which  nerves  come  out  of  the  spinal  cord 
like  bunches  of  white  hair.  Each  hair  later  separates 
from  the  bunch  and  goes  to  a  particular  muscle  or 
organ.  Return  branches  come  back  from  the  surface 
of  the  body  and  from  its  internal  organs,  so  that  the 
nerves  are  like  the  telegraph  wires  to  and  from  a  town 
-  often  bunched  together  in  cables,  but  each  carrying 
its  own  individual  message  to  or  from  the  brain. 

The  brain  itself  is  like  the  central  switchboard  of  a 
telephone  system  with  wires  leading  into  and  out  of  it. 
The  wires  are  the  nerves :  one  set  (sensory  nerves)  lead- 
ing in  from  the  eye,  the  ear,  the  nose,  the  mouth,  the 
skin,  and  all  the  bodily  organs;  another  set  (motor 
nerves')  leading  out  to  the  muscles  and  carrying  com- 
mands for  movement. 

The  brain  is  like  the  telephone  operator,  receiving 
messages  of  sight,  sound,  touch,  smell,  and  taste,  and 
messages  of  pain  from  internal  organs,  interpreting 
those  messages  and  working  them  up  in  thought,  then 
sending  out  commands  for  word  or  deed  through  the 
muscles.  When  the  brain  is  wounded  or  diseased  it 
cannot  receive  messages  (unconsciousness),  or  it  can- 

46 


ANATOMY  AND   PHYSIOLOGY 

not  interpret  them  (insanity  or  feeble-mindedness)  or 
it  cannot  send  out  messages  of  movement  (paralysis, 
speechlessness). 

With  its  substations  in  the  spinal  cord  and  else- 
where the  brain  coordinates  and  marshals  the  organs 
and  energies  of  the  body  so  that  they  work  together. 
Thus  the  nervous  system  as  a  whole  integrates  or  centres 
all  that  goes  on  in  the  hundreds  of  special  activities 
which  make  up  man. 

The  different  parts  of  the  brain  correspond  to  differ- 
ent activities  of  the  body.  The  right  arm  and  leg,  with 
the  right  half  of  the  body,  are  moved  by  the  left  half  of 
the  brain,  while  the  right  half  of  the  brain  corresponds 
similarly  to  the  left  side  of  the  body.  Speech,  hearing, 
and  sight  have  corresponding  centres  in  the  brain,  so 
that  injury  in  one  spot  makes  the  patient  speechless, 
in  another  blind,  in  another  deaf.  Still  other  spots,  or 
centres,  preside  over  the  functions  of  breathing,  vomit- 
ing, etc.,  so  that  brain  disease  may  produce  vomiting, 
or  may  stop  respiration. 

Some  account  of  the  eye,  the  ear  and  the  ductless 
glands  will  be  given  in  the  chapters  on  diseases  of 
those  organs. 


CHAPTER   II 

DISEASES   OF  THE   RESPIRATORY   SYSTEM 

Diseases  of  the  Tonsils 

TONSILLITIS,  the  inflammation  of  the  little  glands  at 
the  beginning  of  the  throat  just  back  of  the  tongue  on 
each  side,  is  a  disease  which  we  are  realizing  more  and 
more  every  year  to  be  very  important  as  a  part  of 
other  diseases.  Tonsillitis  in  itself  is  disagreeable  or 
painful,  not  dangerous.  But  it  is  apparently  the  be- 
ginning of  dangerous  diseases  in  the  heart,  kidneys, 
and  in  the  joints.  We  know  to-day,  what  we  did  not 
know  in  my  student  days,  that  many  if  not  most  cases 
of  "acute rheumatism,"  so  called,  that  is,  inflammation 
of  many  joints  at  once,  start  with  disease  of  the  tonsils. 
To-day  as  we  take  histories  in  hospital  wards  it  is  un- 
usual to  see  a  case  of  rheumatism  which  we  cannot  trace 
to  tonsillitis  or  to  some  other  inflammation  of  the 
mouth.  In  old  times  we  did  not  know  enough  to  ask 
patients  about  this  connection  and  so  we  did  not  find  it. 
I  am  not  going  to  try  to  teach  bacteriology,  but 
there  are  a  few  germs  which  are  mentioned  so  often  in 
the  diagnoses  of  physicians  that  I  must  mention  them. 
Amongst  these  is  the  streptococcus,  a  micro-organism 
growing  in  chains  and  multiplying  by  division.  That 
is  the  germ  concerned  in  septic  sore  throat  or  tonsillitis. 
The  same  germ  is  carried  by  the  blood  from  there  to  the 

48 


DISEASES  OF  THE  RESPIRATORY  SYSTEM 

joints,  causing  acute  rheumatism;  to  the  heart,  causing 
valvular  heart  disease;  and  probably  to  the  brain, 
causing  chorea.  We  used  to  say  that  rheumatism  is 
the  cause  of  heart  disease.  We  now  say  that  both  are 
caused  by  a  single  germ,  the  streptococcus,  which  is  apt 
to  show  itself  first  in  the  tonsils.  It  may  multiply  in 
the  deep  pockets  about  the  roots  of  the  teeth.  Hence 
rheumatism  may  be  due  to  abscesses  about  the  teeth. 
Or  the  streptococcus  may  start  its  work  in  the  cavity 
of  the  cheek  bones,  which  is  called  the  antrum,  and  in  a 
variety  of  other  places. 

But  the  germ  of  tonsillitis  hits  not  merely  the  joints 
and  the  brain  and  the  heart;  it  also  hits  the  kidneys, 
and  I  think  the  most  hopeful  thing  we  have  learned 
about  kidney  disease  in  the  last  ten  years  is  that  it  is 
sometimes  caused  by  the  germ  of  sore  throats.  Chronic 
Bright's  disease  represents  now  one  of  the  most  hope- 
less of  problems.  We  shall  never  cure  it,  but  perhaps 
we  may  learn  to  prevent  it  by  preventing  outbreaks  of 
sore  throat  coming  from  infected  milk  supplies.  Thus 
we  may  reasonably  hope  that  by  campaigns  for  pure 
milk  we  are  preventing  kidney  disease  years  later  - 
for  it  is  years  later  that  the  kidney  effects  of  the  strep- 
tococcus are  most  apt  to  appear. 

We  realize,  then,  that  tonsillitis  is  a  serious  disease 
even  though  it  may  run  its  course  in  a  few  days  and 
seem  to  be  nothing  but  a  bad  cold.  It  is  a  very  bad  cold, 
and  it  may  pull  a  person  down  as  much  as  an  attack 
of  pneumonia.  That  should  be  realized  by  social  work- 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

ers  as  well  as  by  physicians.  A  person  may  need  as 
much  time  for  convalescence  after  tonsillitis  as  after 
pneumonia.  For  since  the  germs  have  been  free  in  the 
blood  stream  and  so  have  poisoned  the  whole  body, 
the  whole  body  needs  time  to  recover.  Many  of  these 
germs  pass  out  of  the  body  through  the  kidneys,  and 
it  is  for  that  reason  that  they  sometimes  stay  there. 
How  else  they  get  out  of  the  body  we  do  not  know. 
Most  of  them  are  presumably  killed  by  the  forces  - 
whatever  those  forces  are  —  that  fight  on  our  side 
against  germs  in  every  infectious  disease.  Some  physi- 
cians believe  that  our  defenders  are  the  leucocytes, 
the  white  corpuscles  of  the  blood;  others  believe  that 
they  are  purely  fluid  substances  circulating  in  the 
blood.  Anyway  it  is  our  forces  of  resistance,  whether 
organized  or  unorganized,  that  do  most  of  the  work  of 
cure  in  germ  disease. 

Quinsy  sore  throat  is  that  type  of  tonsillitis  that  pro- 
duces a  deep  abscess.  Any  tonsillitis  may  run  into  that. 
It  is  more  painful,  but  not  any  more  serious  in  its  re- 
sults. The  abscess  may  break  and  empty  itself  or  may 
need  to  be  opened  with  a  knife. 

Nowadays  we  believe  in  taking  out  the  tonsils  when- 
ever a  person  has  shown  any  signs  of  acute  trouble  in 
many  joints,  or  whenever  a  person  has  repeated  at- 
tacks of  tonsillitis.  We  may  have  half  a  dozen  attacks 
with  no  ill  result,  but  the  seventh  may  be  very  serious. 
I  am  not  enthusiastic  over  taking  out  the  tonsils  for 
many  of  the  reasons  for  which  they  are  removed,  such 

50 


DISEASES  OF  THE  RESPIRATORY  SYSTEM 

as  simple  enlargement,  but  for  their  bad  results  on 
other  parts  of  the  body  they  should  often  come  out,  in 
my  opinion.  If  they  are  thoroughly  removed  by  a  man 
who  knows  his  job,  they  rarely  form  again  and  a  person 
is  free  from  that  particular  danger. 

There  is  no  local  treatment  of  the  throat  that  will 
cure  or  prevent  tonsillitis;  spraying  and  gargling  may 
give  some  temporary  relief  to  persons  who  like  them, 
but  they  will  not  cure,  for  it  is  like  spraying  the  front 
of  a  house  when  the  fire  is  in  the  back  yard.  We  hope 
that  improved  milk  supplies  and  pasteurization  may  Y 
prevent  a  good  deal  of  the  tonsillitis  now  so  rampant. 

Streptococci  attack  the  antrum,  producing  pus  or 
"  empyema  of  the  antrum."  They  can  attack  any  tissue 
of  the  body.  In  the  pharynx  they  produce  pharyngitis, 
in  the  larynx,  laryngitis,  in  the  nose,  coryza,  and  in  the 
bronchi  bronchitis.  The  streptococcus  is  the  most  uni- 
versal invader  of  the  body,  and  I  suppose,  directly  or 
indirectly,  it  causes  more  deaths  than  any  other  germ. 
But  other  germs  can  also  cause  any  of  the  inflamma- 
tions just  mentioned. 

Hypertrophied  tonsils  and  adenoids  in  children.  Chil- 
dren usually  have  four  "tonsils"  or  bunches  of  lymph 
gland  tissue  at  the  entrance  to  the  throat.  Those  at 
each  side  opposite  the  base  of  the  tongue  are  usually 
called  "the  tonsils";  faucial  tonsils  is  their  technical 
name. 

A  third,  the  adenoid,  is  at  the  junction  of  the  nasal 
cavities  with  the  throat. 


A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

A  fourth,  the  lingual  tonsil,  is  at  the  root  of  the 
tongue,  farther  down  the  throat. 

Besides  these  four  chief  islands  of  tissue  there  are 
countless  smaller,  unnamed  islets  and  reefs  of  tissue 
scattered  about,  especially  on  the  back  wall  of  the 
throat. 

The  use  of  all  these  lumps  no  one  knows.  They 
ordinarily  do  no  harm,  but  if  the  adenoid  is  very  large  it 
may  block  nasal  breathing,  and  if  any  of  the  tonsils 
are  frequently  inflamed  they  may  lead  to  attacks  of 
ear  trouble.  For  these  two  reasons  they  are  often  and 
properly  removed. 

But  if  they  are  merely  prominent  and  noticeable  in 
the  throat  without  preventing  the  child  from  breathing 
through  its  nose,  without  blocking  the  tubes  which  lead 
from  the  throat  to  the  ears  (Eustachian  tubes),  and 
without  frequent  "sore  throats,"  there  is,  I  think,  no 
good  reason  for  removing  them.  Many  operations  are 
done  merely  for  "big  tonsils,"  or  for  "tonsils  and  ade- 
noids," when  there  is  no  evidence  of  any  harm  in  them 
or  of  any  need  for  the  operation. 

Nasal  obstruction  (with  resultant  mouth-breathing) ; 
frequent  earaches  (or  a  sense  that  the  ears  are  "stuffed 
up");  frequent  sore  throats  (tonsillitis),  are  the  chief 
local  reasons  for  removing  tonsils  and  adenoids. 

In  addition  to  these  local  reasons  for  operation  there 
are  the  distant  or  constitutional  reasons,  such  as  heart 
trouble,  joint  trouble,  or  unexplained  fever.  When 
these  troubles  are  present  it  is  always  possible  that  the 

52 


DISEASES  OF  THE  RESPIRATORY  SYSTEM 

tonsils  and  inflammation  in  them  are  the  cause.  Hence 
an  experimental  operation  is  often  justified  in  order  that 
we  may  remove  a  possible  cause  of  serious  disease  in 
other  organs.  Any  tonsil  or  adenoid,  large  or  small, 
healthy-looking  or  obviously  diseased,  may  justifiably 
be  removed  as  an  experiment  when  there  is  disease  of 
heart  or  joints  unexplained.  But  we  cannot  truly  say, 
"Operate,  for  it  can't  do  harm  and  may  do  good." 
It  may  do  harm.  Hemorrhage  and  other  very  serious 
ill  effects  occur  once  in  so  often  with  almost  every  oper- 
ator, and  these  possibilities  must  be  balanced  against 
the  possible  good  of  the  operation.  If  the  latter  is  con- 
siderable, it  outweighs  the  former,  provided  a  first-rate 
operator  is  available.  The  best  operators  are  those  of 
largest  experience  with  this  particular  operation  and 
those  most  surely  free  from  any  taint  of  commercialism. 

Tonsils  and  adenoids  usually  shrivel  up  and  disap- 
pear or  become  harmless  about  the  age  of  puberty 
(twelve  to  sixteen).  Hence  the  nearer  the  child  to  this 
age,  the  less  reason  (other  things  being  equal)  for 
operating. 

To  count  as  "a  defect'*  every  prominent  tonsil  or 
adenoid  found  in  the  routine  examination  of  school 
children  is  folly. 

Diseases  of  the  Nasal  Cavities 

are  important  to  understand  chiefly  because  so  many 
unnecessary  operations  are  done  upon  them.  There  are 
a  great  number  of  symptoms  at  a  distance  from  the 

53 


A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

nasal  cavity  which  are  supposed  by  some  physicians, 
especially  those  who  make  a  specialty  of  diseases  of 
the  nose  and  throat,  to  be  due  to  conditions  in  that 
cavity,  and  in  consequence  there  are  a  great  many 
over-enthusiastic  operations  upon  the  septum  (the 
cartilage  which  divides  the  two  sides  of  the  nose)  and 
upon  the  curled-up  or  " turbinate"  bones  on  either  side 
of  that  septum.  The  main  thing  is  for  the  patient 
to  be  sure,  whenever  such  an  operation  is  proposed, 
that  it  is  really  necessary.  It  is  often  done  without 
sufficient  cause,  and  with  resulting  disappointment  to 
the  patient  and  diminution  of  his  income.  Within  this 
year  I  have  had  occasion  to  save  two  social  workers 
from  unnecessary  operations  in  this  field  by  recom- 
mending them  to  a  nose  and  throat  specialist  who 
never  operates  unless  it  is  necessary.  We  should 
search  out  that  type  of  surgeon  and  be  sure  that  our 
friends  do  not  go  through  unnecessary  disappointment 
and  loss  of  money  because  of  useless  or  faddish  opera- 
tions. Probably  the  two  regions  of  the  body  in  which 
unnecessary  operations  are  most  often  done  are  the 
nose  and  the  female  genital  tract. 

In  the  nose  and  behind  it,  where  it  opens  into  the 
throat,  a  great  many  persons  have  "  catarrh"  a  chronic, 
nearly  harmless  inflammation  which  causes  phlegm  to 
drop  down  into  the  throat.  Sometimes  this  disease  can 
be  checked  by  stopping  tobacco  or  by  moving  to  a 
warm,  dry,  clear  climate,  or  by  getting  out  of  a  dusty 
trade.  Local  treatment  by  sprays,  washes,  and  gargles 

54 


DISEASES  OF  THE   RESPIRATORY  SYSTEM 

is  nearly  or  quite  useless,  and  as  a  rule  the  best  way  is 
to  grin  and  bear  the  very  moderate  inconvenience  of 
the  catarrh.  It  has  no  connection  with  serious  diseases 
like  tonsillitis,  pneumonia,  or  tuberculosis,  and  rarely 
if  ever  produces  joint  troubles. 

Of  the  larynx  I  have  but  little  to  say  before  we 
leave  this  section  of  the  body.  Ordinary  laryngitis 
produces  the  hoarseness  and  finally  the  loss  of  voice 
that  we  get  as  part  of  a  bad  cold,  but  it  is  a  rather  in- 
teresting thing  that  men  and  women  react  very  differ- 
ently to  it.  When  a  man  has  laryngitis  his  voice  be- 
comes a  deep  bass;  he  growls  a  few  days  and  then  is 
well.  But  when  a  woman  with  a  soprano  voice  has 
laryngitis,  she  does  not  become  an  alto;  she  does  not 
as  a  rule  have  any  change  in  the  pitch  of  her  voice. 
She  "loses  her  voice"  altogether,  and  after  the  inflam- 
mation has  passed  away  she  often  has  considerable 
trouble  in  finding  her  voice  again.  The  nervous  con- 
nection between  the  brain  and  the  vocal  cords,  the  ar- 
rangement whereby  she  can  speak  when  she  wants  to 
speak,  has  apparently  been  broken  during  the  period  of 
laryngeal  inflammation,  and  after  this  has  gone  it  is 
sometimes  very  difficult  to  get  the  connection  estab- 
lished again.  The  nerve  coming  from  the  brain  to  the 
vocal  cord  is  not  broken  by  disease;  it  is  only  the 
function  of  the  nerve  that  is  in  abeyance.  The  com- 
munication between  the  will-act  in  the  mind  and  the 
movement  of  the  muscle,  a  communication  which  we 
suppose  goes  through  the  nerve,  is  somehow  lost  and 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

must  somehow  (by  shock,  or  fear,  or  surprise)  be  found 
again. 

Laryngologists  get  very  skilful  in  devising  tricks 
whereby  this  type  of  voicelessness  or  aphonia  can  be 
relieved.  Sometimes  a  doctor  will  startle  his  voiceless 
patient  into  singing,  which  can  then  be  reduced  to 
speaking;  or  he  starts  her  coughing  or  making  some 
noise,  after  which  speech  connection  is  restored.  Be- 
cause these  manoeuvres  have  very  little  medicine  and  a 
good  deal  of  psychology  in  them,  the  impression  that 
these  cases  are  all  "hysterical"  has  gained  ground. 
Of  course  there  are  cases  of  true  hysterical  aphonia, 
but  a  good  many  persons  are  accused  of  it  who  have 
this  other  type,  starting  in  an  ordinary  cold.  The  prog- 
nosis is  perfectly  good  in  all  cases.  The  voice  always 
comes  back,  and  that  can  be  said  to  the  patient  with 
entire  truth  and  confidence. 

The  question  is  often  asked,  in  connection  with  oper- 
ations on  the  nose  or  throat,  whether  a  social  worker 
should  " steer"  a  patient  away  from  one  doctor  and 
to  another.  I  think  it  is  her  job,  like  the  job  of  any 
other  friend,  to  try  to  get  the  patient  in  contact  with 
somebody  who  will  make  a  right  diagnosis.  These  are 
delicate  situations,  but  if  a  person  is  really  suffering, 
whether  from  medical  ignorance  or  from  any  other 
cause,  social  workers  should  not  fail  to  do  what  they 
can  to  get  him  in  touch  with  the  best  sources  of  health. 
Of  course  a  social  worker  ought  to  be  distrustful  of  her 
own  judgment.  She  ought  to  be  as  sure  as  she  possibly 

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DISEASES  OF  THE  RESPIRATORY  SYSTEM 

can  be  before  she  takes  it  upon  herself  to  steer  a  person 
away  from  one  doctor  to  another.  The  necessity  is 
comparatively  rare.  But  it  exists. 

Diseases  of  the  Lungs 

I  shall  skip  tuberculosis,  because  it  is  the  one  disease 
which  has  been  written  up  for  social  workers  repeat- 
edly, and  especially  well  by  Dr.  John  B.  Hawes,  2d, 
of  Boston.1 

First,  bronchitis.  For  a  social  worker  the  most  im- 
portant thing  about  bronchitis  is  to  realize  that  it  is 
rather  rare,  and  that  hence  we  should  always  suspect 
the  diagnosis.  It  is  generally  a  wrong  diagnosis.  The 
better  the  physician,  the  more  seldom  he  makes  this 
diagnosis.  Most  diagnoses  of  chronic  bronchitis  are 
really  tuberculosis  or  heart  disease.  Most  of  us  can 
recollect  cases  in  our  own  experience  which  have  been 
called  "bronchitis"  before  the  real  nature  of  the  dis- 
ease was  recognized  (phthisis  or  heart  disease  as  a 
rule).  This  mistake  happens  occasionally  even  under 
the  best  conditions.  The  patient,  when  last  she  was 
seen,  had  what  was  called  bronchitis;  seeing  her  four 
months  later,  the  diagnosis  is  obviously  tuberculosis 
in  an  advanced  stage.  The  golden  moment  has  passed 
by- 

Children  certainly  do  have  acute  bronchitis  quite 
frequently,  without  the  diagnosis  needing  to  be  re- 

1  John  B.  Hawes,  2d,  M.D. :  Early  Pulmonary  Tuberculosis:  Diagnosis, 
Prognosis,  and  Treatment.  New  York:  William  Wood  &  Co.  1913. 

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vised  or  suspected,  but  even  in  children  I  think  it  is  a 
good  plan  for  us  to  be  dubious  of  a  diagnosis  of  bron- 
chitis unless  made  by  an  expert.  I  always  doubt  my 
own  diagnosis  in  such  cases.  There  are  very  few  physi- 
cians who  are  capable  of  making  it  correctly.  This  is 
especially  true  of  chronic  bronchitis.  (Chronic  means 
of  long  standing.  Acute  means  short,  not  necessarily 
severe.  A  cold  in  the  head  is  an  acute  coryza.)  A 
chronic  bronchitis  is  a  long  bronchitis.  Even  in  chil- 
dren that  is  a  great  rarity.  * 

In  adults,  and  especially  in  elderly  men,  the  diag- 
nosis of  chronic  bronchitis  should  generally  be  revised 
to  read  heart  disease  —  heart  disease  with  poor  circula- 
tion through  the  lung  and  with  resulting  cough.  When, 
owing  to  disease  of  the  heart,  the  blood  does  not  cir- 
culate freely  through  the  lung,  it  oozes  out  of  the 
vessels  and  into  the  lung  itself  and  there  irritates  the 
lung  until  it  is  drained  by  cough.  That  oozing  is  swel- 
ling or  edema  of  the  lungs,  a  symptom  of  heart  disease 
and  not  an  independent  disease. 

Chronic  bronchitis,  in  the  few  cases  in  which  it 
really  does  exist  and  is  not  mistaken  for  phthisis  or 
heart  disease,  almost  never  kills.  People  should  insist, 
in  this  and  in  other  diseases,  on  knowing,  not  how  to 
diagnose,  but  what  to  expect  in  any  common  disease; 
that  is,  prognosis,  or  the  outlook.  The  expectations 
from  a  given  diagnosis  is  a  thing  I  think  social  workers 
and  laymen  generally  cannot  know  too  much  of,  for 
the  social  plan  depends  upon  this.  If  the  person  is 

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DISEASES  OF  THE   RESPIRATORY  SYSTEM 

going  to  live  but  a  few  days,  we  take  a  different  course 
from  that  which  we  should  take  if  he  is  likely  to  re- 
cover. 

Chronic  bronchitis  does  not  disable  people  alto- 
gether, and  never  kills.  It  gives  a  chronic  cough  with 
no  tubercle  bacilli  discoverable  in  the  sputum  and 
with  a  sound  heart.  It  often  results  in  stretching  the 
bronchi,  and  the  result  is  a  disease  known  as  bronchi- 
ectasis,  which  means  the  stretching  of  a  bronchus. 
Secretions  of  phlegm  and  pus  accumulate  there  and 
have  to  be  emptied  out  with  an  attack  of  cough  from 
time  to  time.  This  is  a  rather  rare  complication  of 
chronic  bronchitis,  seen  more  often  in  young  people 
than  in  old  people.  It  is  too  rare  to  warrant  my  going 
into  more  details  about  it. 

The  treatment  of  coughs,  due  to  chronic  bronchitis 
and  other  causes,  should  be  limited  to  those  which 
keep  people  awake  or  seriously  exhaust  them.  A  cough 
in  itself  is  usually  a  good  thing,  because  it  helps  to  take 
out  of  the  lung  what  ought  to  come  out.  But  like 
other  of  the  self-protecting  arrangements  of  the  human 
body,  the  cough  reflex  now  and  then  overdoes  things. 
It  is  very  characteristic  of  the  human  body  to  make 
most  ingenious  and  intelligent  attempts  to  rid  itself  of 
disease,  and  to  accomplish  it  in  part,  but  then  to  overdo 
the  attempt.  A  cough  sometimes  becomes  a  habit, 
goes  on  when  there  is  no  need  for  it,  and  keeps  people 
awake.  Then  it  should  be  checked.  We  can  all  help 
to  train  people  out  of  the  idea  that  every  cough  needs 

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A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

medicine.  In  the  first  place,  very  few  coughs  can  be 
stopped  by  medicine,  and  in  the  second,  the  drug 
would  probably  do  harm  if  it  could  check  the  cough. 

The  well-trained  physician  knows  which  cough 
should  be  stopped,  and  when  it  should  be  stopped.  He 
has  at  his  disposal  two  classes  of  medicines  about 
which  it  is  well  to  know  something.  One,  the  opiates, 
check  cough  by  checking  the  sensation  which  demands 
cough,  the  tickle.  The  form  of  opiate  most  often  used 
is  heroin,  and  like  all  the  other  opiates,  it  cannot  now 
be  obtained  in  this  country  without  a  special  prescrip- 
tion of  which  account  is  kept  by  the  United  States 
Government,  so  that  we  now  know  who  is  using  and 
who  is  over-using  these  drugs.  To  stop  a  cough  no 
patient  should  take  heroin,  codeia  or  any  opiate  for 
more  than  a  week.  We  must  realize  that  patients  are  in 
danger  of  contracting  a  heroin  habit,  just  as  much  as  a 
morphia  habit.  Heroin  does  not  have  the  bad  immedi- 
ate results  of  morphia.  If  one  takes  morphia  to-day  he 
will  feel  miserable  to-morrow,  but  if  he  takes  heroin  he 
will  feel  very  well  to-morrow.  Hence  its  evils  are  all  the 
more  insidious.  Yet  heroin  does  no  harm  if  it  is  not  kept 
up  more  than  a  few  days,  and  it  is  a  wonderful  drug  for 
stopping  night  cough. 

The  other  medicines  for  cough  are  those  which  in- 
crease the  amount  of  expectoration  when  it  is  scanty 
and  will  not  come  up.  The  best  of  these  is  iodide  of 
potassium,  the  familiar  drug  which  the  doctor  calls 
K.I.  It  is  important  to  know  this,  because  every  now 

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DISEASES  OF  THE  RESPIRATORY  SYSTEM 

and  then  I  have  found  a  social  worker  making  the  mis- 
take of  thinking  that  a  patient  had  syphilis  because  he 
was  taking  K.I.  and  K.I.  is  so  often  used  for  syphilis. 
But  this  drug  has  several  other  uses,  one  of  these  being 
for  the  relief  of  cough.  Another  use  is  for  lead  poison- 
ing. We  must  not,  therefore,  suspect  a  patient  of 
syphilis  merely  because  he  has  taken  K.I. 

Besides  these  two  groups  of  cough  medicines  there 
are  innumerable  others  still  given  by  some  doctors, 
because  the  patient  demands  it,  but  they  are  for  the 
most  part  useless 

Asthma 

Asthma  is  a  disease  which  begins  in  early  youth.  If 
we  hear  of  any  one  who  is  supposed  to  have  contracted 
asthma  or  to  show  asthma  past  middle  life,  we  can 
usually  be  sure  that  the  diagnosis  is  wrong.  This  is 
important  because  in  such  cases  the  true  diagnosis  is 
usually  that  of  a  progressive  disease;  namely,  kidney 
trouble  or  heart  trouble.  Asthma  begins  in  youth  and 
is  often  outgrown  or  spontaneously  cures  itself  as  life 
advances.  There  is  no  cure  for  the  disease,  but,  as  I 
have  said,  it  may  get  well  of  itself.  Climate  helps 
many,  any  climate  different  from  that  in  which  they 
got  the  disease. 

Asthma  is  a  paroxysm  of  short  breath  with  wheezing 
and  cough,  coming  on  suddenly,  often  at  night,  lasting 
hours  or  at  the  most  a  day  or  two,  and  then  leaving  a 
person  altogether.  The  disease  consists  in  a  series  of 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

such  paroxysms.  To  one  who  has  not  seen  it  before,  it 
is  most  alarming,  but  nobody  ever  dies  of  it.  The  person 
is  often  waked  from  sleep,  jumps  out  of  bed,  runs  to 
the  window,  but  may  be  all  right  and  go  to  business  in 
the  morning.  It  is  set  up  by  various  dusts.  Some  peo- 
ple get  it  from  hay  along  with  "hay  fever"  or  without 
it.  Some  people  get  it  from  feathers;  e.g.,  sleeping  on 
a  feather  pillow.  Some  people  get  it  from  the  breath 
of  a  horse,  after  driving  behind  one. 

Asthma  lasts  for  years,  but  does  not  generally  handi- 
cap a  person  very  seriously  in  relation  to  work.  Igno- 
rant people  and  some  not  so  ignorant  waste  their 
money  on  drugs  for  it  and  especially  on  those  contain- 
ing cocaine,  a  dangerous,  habit-forming  drug. 

Emphysema  means  a  distension,  a  blowing-up  of  the 
lungs,  with  loss  of  their  elasticity,  so  that  breathing  is 
not  easily  carried  on.  Normally  the  lungs  are  expanded, 
as  we  breathe  in,  by  muscular  effort.  As  we  breathe 
out,  they  collapse  by  elasticity,  like  a  rubber  strap. 
Take  away  that  elasticity  and  they  do  not  empty 
themselves  easily,  but  remain  permanently  in  the  po- 
sition of  full  inspiration.  The  disease  happens  most 
often  in  elderly  men,  without  known  cause;  less  often 
in  women.  It  is  incurable.  Emphysema  is  usually  only 
a  small  portion  of  the  true  diagnosis.  Patients  have 
emphysema  with  something  else — usually  with  asthma 
or  bronchitis,  and  especially  often  with  arteriosclerosis 
(hardening  of  the  arteries).  The  chief  thing  to  know 
is  that  it  gives  shortness  of  breath  with  cough  and 

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DISEASES  OF  THE  RESPIRATORY  SYSTEM 

wheezing,  and  so  moderately  but  permanently  dimin- 
ishes working  power,  although  it  is  hard  to  distinguish 
what  it  takes  away  from  the  man  from  what  is  taken 
away  by  the  accompanying  arteriosclerosis.  There  is 
no  treatment,  as  I  have  said,  and  it  goes  on  for  a  great 
many  years.  Finally  the  heart  fails  unless  the  patient 
dies  of  some  other  disease. 

Pleural  Effusion 

(a)  Purulent  Pleurisy.  It  is  important  to  distinguish 
emphysema  from  another  disease  the  name  of  which, 
empyema,  is  a  good  deal  like  it,  so  that  mistakes  may 
occur.  Empyema  is  literally  a  collection  of  pus  in  any 
portion  of  the  body.  Thus  we  may  have  empyema 
of  the  antrum  or  of  the  gall-bladder.  But  when  one 
says  "  empyema  "  alone,  one  means  a  collection  of  pus 
in  the  pleura;  that  is,  in  the  empty  sac  between  the 
lungs  and  the  chest  wall. 

Empyema,  or  purulent  pleurisy,  has  two  main  types, 
the  post-pneumonic  and  the  tuberculous.  Post-pneu- 
monic empyema,  a  common  sequel  of  pneumonia,  is 
usually  cured  by  surgical  drainage,  but  is  often  over- 
looked and  mistaken  for  a  failure  of  the  pneumonia  to 
" resolve"  or  get  well  as  it  ordinarily  does  within  ten 
days.  Empyema,  like  any  collection  of  pus,  produces 
fever  and  chills  for  weeks  or  months.  Whenever  a  per- 
son has  fever  and  chills,  —  if  malaria  can  be  excluded, 
-  then  pus  somewhere  in  the  body  is  the  probable 
cause.  Any  collection  of  pus  causes  a  series  of  chills 

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once  a  day  or  oftener  with  irregular  fever,  from  which 
the  patient  becomes  emaciated  and  weak. 

With  surgical  drainage  a  cure  is  complete  within  a 
few  months  in  practically  every  case  of  post-pneumonic 
empyema.  If  an  empyema  does  not  heal  after  "  drain- 
age," —  that  is,  after  two  or  three  inches  of  a  rib  have 
been  taken  out,  the  pus  removed,  and  a  drainage  tube 
put  in,  —  then  it  is  in  all  probability  the  other  type, 
tuberculous. 

I  saw  in  my  clinic  the  other  day  a  woman  whom  I 
first  attended  in  1899;  she  has  had  a  discharging  em- 
pyema ever  since.  She  has  tuberculosis  of  the  lungs 
with  accompanying  tuberculosis  of  the  pleura  and  a 
discharging  empyema.  Practically  never  does  a  tuber- 
culous empyema  heal.  The  person  has  a  chronic  sinus, 
which  means  a  hole  leading  from  the  empyema  inside 
to  the  external  world,  and  constantly  discharging  pus. 
Usually  such  patients  die  of  tuberculosis.  Yet  the 
woman  whom  I  saw  the  other  day  has  been  doing  her 
housework  through  most  of  these  years  in  spite  of 
some  fever,  and  now  weighs  two  hundred  pounds.  She 
is  an  old  established  figure  in  the  clinic.  But  most 
people  die  of  the  trouble  within  a  few  years. 

We  recognize,  then,  two  types  of  empyema  with  dif- 
ferent prognoses,  —  the  one  good,  short,  the  other  bad, 
long ;  death  is  finally  produced  through  the  self-poison- 
ing or  absorption  of  poison  from  the  purulent  pocket. 

(b)  Tuberculous  Pleurisy  ("dry"  or  serous).  There 
are  other  types  of  pleurisy,  of  which  two  are  especially 

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DISEASES  OF  THE  RESPIRATORY  SYSTEM 

important,  —  dry  pleurisy  and  pleurisy  with  serous 
effusion.  Dry  pleurisy  is  the  cause  of  a  pain  in  the  side 
which  lasts  days  or  possibly  weeks,  and  goes  off  usu- 
ally after  causing  adhesions  of  the  two  pleural  surfaces. 
The  lung  sticks  to  the  chest  wall,  extensive  scars  unite 
the  two,  and  that  is  the  end  of  it.  If  it  does  no  more 
than  that,  it  does  no  harm.  Often  it  goes  on  to  "  effu- 
sion"; that  is,  a  serous  fluid,  like  the  fluid  part  of 
the  blood,  clear,  pale  straw-colored,  is  poured  into  the 
pleura,  —  a  pint,  a  quart,  even  more  in  severe  cases,  — 
so  that  the  danger  to  life  may  be  considerable  from 
pressure  on  the  heart.  This  danger  is  very  easily  re- 
moved by  "tapping  the  chest."  Tapping  is  almost  the 
only  operation  still  allowed  to  medical  men  who  are 
not  surgeons.  It  consists  merely  in  putting  a  hollow 
needle  between  the  ribs  (which  under  cocaine  causes  no 
pain) ,  and  letting  the  fluid  run  out  through  that  needle. 

This  type  of  pleurisy  can  be  cured  in  most  cases  by 
a  single  tapping.  In  the  other  cases  two  tappings  are 
needed,  practically  never  three. 

Dry  pleurisy  and  pleurisy  with  effusion  almost  always 
mean  tuberculosis  —  not  necessarily  tuberculosis  of  the 
lungs,  but  tuberculosis  of  the  pleura,  with  a  possi- 
bility of  its  extension  to  the  lung  or  to  other  organs. 
To  social  workers  the  important  point  is  that  these 
patients  should  be  treated  exactly  as  if  they  had  tuber- 
culosis of  the  lungs.  They  should  be  given  the  benefits 
of  a  sanatorium  if  possible,  and  taught  all  that  we 
teach  tuberculosis  patients  about  food,  rest,  and  fresh 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

air.  A  great  many  now  develop  phthisis,  but  most 
would  not,  in  all  probability,  if  they  were  treated  from 
the  start  like  patients  with  phthisis. 

Pneumonia 

Pneumonia  is  an  acute  germ  disease  which,  in  prac- 
tically every  case,  is  over  within  ten  days.  It  is  im- 
portant to  know  this  because  if  we  hear  of  a  person 
who  has  what  is  supposed  to  be  pneumonia  and  whose 
illness  hangs  on  for  weeks,  we  may  be  very  suspicious. 
The  true  diagnosis  is  usually  tuberculosis  or  empyema. 
A  person  needs  good  nursing  and  fresh  air  in  pneu- 
monia, and  that  is  about  all.  There  is  very  little  that 
we  physicians  can  do  at  the  present  time  to  cure  pneu- 
monia. It  is  a  very  sharp  illness,  but  short,  and  the 
drain  upon  the  patient's  finances  is  not  often  great  if 
we  have  the  true  diagnosis.  About  twenty-five  per 
cent  of  all  adult  cases  die.  When  it  occurs  in  alcoholics, 
about  seventy-five  per  cent  die.  This  is  one  of  the  best 
established  examples  of  the  harm  that  alcohol  does  in 
people  whom  it  does  not  make  drunk.  A  man  who  is 
never  drunk  at  all,  but  is  chronically  alcoholic,  when 
he  gets  pneumonia  is  three  times  as  apt  to  die  as  the 
total  abstainer. 

The  doctor  is  almost  never  to  blame  for  the  death  in 
pneumonia,  nor  responsible  for  the  recovery  in  favor- 
able cases.  In  children  outdoor  treatment  seems  to 
help  very  much,  but  children  do  much  better  than 
adults  anyway. 

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CHAPTER  III 

DISEASES   OF   THE  HEART  AND  ARTERIES 

Diseases  of  the  Heart 

DISEASES  of  the  heart  seldom  manifest  themselves  by 
pain,  or  if  there  is  pain  it  is  usually  a  subordinate  ele- 
ment. It  is  important  to  know  that  a  pain  in  the  left 
side  of  the  chest  is  usually  not  heart  disease,  just  as 
a  pain  in  the  kidneys  usually  means  sound  kidneys. 
Heart  disease  manifests  itself  ordinarily  by  shortness 
of  breath  and  swelling  of  the  legs :  by  shortness  of  the 
breath,  because  the  lungs  are  blocked  owing  to  poor 
circulation  through  them;  by  swelling  of  the  legs,  be- 
cause it  takes  more  work  to  get  the  blood  up  from  the 
lowest  parts  of  the  body  —  that  is,  from  the  legs  —* 
than  to  get  it  down  from  the  head  and  arms.  Therefore, 
when  the  heart  fails,  the  damage  is  seen  first  in  that 
portion  of  the  blood  stream  which  takes  most  work  on 
the  part  of  the  heart  to  keep  going.  A  little  later  the 
patient  becomes  unable  to  lie  down  at  night  because 
he  cannot  breathe,  and  with  that  comes  a  cough  which 
is  very  hard  to  relieve  until  the  heart  itself  is  relieved. 
From  the  layman's  point  of  view  the  most  important 
point  about  heart  disease  is  its  prognosis,  and  from  that 
standpoint  I  shall  divide  the  cases  into  four  groups : 

(1)  Rheumatic  (3)  Arteriosclerotic 

(2)  Syphilitic  (4)  Nephritic 

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^   By  rheumatic  heart  disease  one  means  a  type  whi 
seems  to  originate  either  in  what  is  called  "acute 
rheumatism,"  attacking  many  joints,  or  in  tonsillitis, 
which  is  the  source  of  most  cases  of  rheumatism,  or  in 


chorea,  which  is  probably  a  manifestation  of  the  same    t 
disease  in  the  brain.   The  streptococcus,  the  organism    0 
which  is  back  of  this  disease,  may  show  itself  first  in 
the  throat  (tonsillitis),  or  in  the  brain  (chorea),  in  the 
joints  (rheumatism),  or  in  the  heart  as  endocarditis  (in- 
flammation of  the  heart  valves).    Endocarditis  means 
literally  inflammation  of  the  inside  of  the  heart,  but  * 
practically  of  that  portion  of  the  inside  of  the  heart 
which  is  on  the  valves.   It  does  no  known  harm  unless 
it  is  on  or  near  the  valves. 

Rheumatic  heart  disease  begins  usually  in  childhood. 
It  rarely  begins  after  twenty-one,  and  is  almost  twice 
as  common  in  girls  as  in  boys.  It  is  the  children's  heart 
disease,  and  practically  the  only  one,  with  the  excep- 
tion of  the  rare  congenital  defects  of  the  heart. 

This  type  of  heart  disease  carries  the  best  prognosis 
of  the  four.  People  can  live  fifty  years  with  it  and  die 
of  something  else.  They  can,  but  they  generally  do  not, 
because,  before  they  get  to  be  twenty-one,  fresh  acute 
crops  of  the  streptococcus  get  in  upon  the  heart  and 
extend  the  damage  done  the  first  time.  These  recur- 
rent acute  attacks  in  children  result  in  the  heart's  be- 
coming so  badly  damaged  that  it  cannot  get  along. 
This  usually  occurs  before  twenty-one;  hence,  we  say 
to  the  parents  of  such  children,  "  If  you  can  take  extra 

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E^EASES  OF  THE  HEART  AND  ARTERIES 

v 

care  of  your  children  up  to  twenty-one,  even  though  the 

heart  seems  to  be  doing  pretty  poor  work,  the  chances 
are  good  that  it  will  settle  down  and  be  a  useful  or- 
gan for  the  rest  of  life."  I  know  of  one  case  in  my 
own  observation  where  the  trouble  has  existed  for 
twenty-seven  years.  I  happened  to  make  a  guess  at 
the  diagnosis  just  before  I  became  a  medical  student, 
and  it  was  confirmed  by  an  expert.  That  "patient" 
can  still  do  all  his  work  and  can  enter  athletics  as  well. 
The  possibility  of  going  on  in  this  way  is  dependent 
upon  what  we  call  good  compensation.  A  well-com- 
pensated case  of  heart  disease  may  leave  its  possessor 
able  to  work  for  many  years.  "Compensation"  means 
that  the  heart  strengthens  itself,  thickens  its  own 
muscle,  and  enlarges  its  own  cavities  so  as  to  overcome 
the  defects  in  its  valves.  For  instance,  if  a  valve  leaks, 
so  that  the  fluid  which  should  go  ahead  goes  back  in- 
stead, that  leak  is  compensated  by  extra  strength  in 
the  pumping  wall  of  the  heart.  The  heart  may  grow  to 
three  or  four  times  its  natural  weight  in  this  process  of 
compensating  for  diseased  valves.  In  time  it  may 
thus  become  so  strong  that  a  man  with  diseased  valves 
may  be  able  to  play  golf  or  tennis,  and  even  to  swim. 
Failure  of  compensation  occurs  in  children  mostly  when 
they  get  acute  febrile  attacks  of  fresh  poisoning  from 
the  streptococcus.  When  compensation  fails,  either 
from  this  cause  or  from  overexert  ion,  we  get  the  symp- 
toms mentioned  above,  —  swelled  feet,  short  breath, 
difficulty  in  lying  down  at  night,  finally  general  dropsy. 

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The  next  type  of  heart  disease,  the  syphilitic,  gives  % 
with  one  exception  the  worst  prognosis.  The  syphilitic 
heart  does  not  often  survive  five  years.  It  is  seen  in 
young  and  middle-aged  men,  far  less  often  in  women, 
almost  never  in  children,  seldom  in  the  old.  The  diag- 
nosis rests  largely  upon  the  blood  test  (the  "Wasser- 
mann  reaction  ")  and  the  history,  and  often  is  not  made 
because  the  Wassermann  test  is  not  made.  Yet  cor- 
rect diagnosis  is  important,  because  the  outlook  is 
quite  different  and  the  treatment  is  different  from  that 
of  any  other  type  of  heart  disease.  The  treatment  is 
that  of  syphilis  plus  certain  measures  advisable  in  all 
kinds  of  heart  trouble. 

The  third  type,  arteriosclerotic  heart  disease,  is  the 
old  man's,  less  often  the  old  woman's,  heart  trouble  — 
the  failing  heart  of  old  age.  It  practically  always  goes 
with  high  blood  pressure  as  well  as  with  degeneration 
of  the  arteries  in  various  parts  of  the  body.  Hardening 
of  the  arteries,  what  is  called  "arteriosclerosis,"  and 
high  blood  pressure,  mean  that  the  tubes  through 
which  the  blood  flows  become  smaller  and  stiffer  than 
they  normally  are.  Hence  it  is  more  work  for  the  heart 
to  force  the  blood  through  these  small  stiff  tubes  than 
it  was  through  the  elastic  vessels  of  youth.  The  heart, 
therefore,  is  called  upon  for  more  work;  it  " compen- 
sates," or  hypertrophies  as  we  say;  that  is,  it  gets 
larger.  Hypertrophy  means  simply  growing  larger. 
When  one  exercises  one's  biceps  muscle,  it  hypertro- 
phies; when  one  overworks  one's  heart,  it  hypertro- 

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DISEASES  OF  THE  HEART  AND  ARTERIES 

phies.  Thus  for  years  the  trouble  is  compensated  so 
that  these  people  may  get  along  fairly  well.  In  time 
the  load  becomes  too  great,  the  heart  weakens,  and 
death  comes. 

Next  to  the  rheumatic  type,  the  arteriosclerotic 
heart  gives  the  best  prognosis.  People  with  this  type 
of  heart  trouble  may  live  ten  or  fifteen  years.  They  are 
more  or  less  seriously  disabled  all  the  time,  but  ca- 
pable of  enjoying  life  if  they  do  not  try  to  do  any- 
thing strenuous.  They  have  no  working  future  as 
patients  with  rheumatic  hearts  have,  but  they  do  not 
die  rapidly,  and  in  the  early  years  of  the  trouble  suffer 
little  if  they  are  quiet. 

It  is  in  this  type  chiefly  that  one  sees  pain  in  the 
heart.  I  have  said  that  heart  pain  is  rare.  But  in  this 
type  we  do  occasionally  get  the  characteristic  heart 
pain,  angina  pectoris.  Angina  pectoris  means  a  pain 
in  the  region  of  the  heart  which  comes  on  after  exer- 
tion or  emotion  and  is  relieved  by  rest.  We  often  see 
in  the  streets  a  pathetic  figure  pretending  to  look  into 
the  shop  windows  when  he  does  not  really  want  to. 
Perhaps  he  has  angina,  has  been  caught  by  this  pain 
and  must  stop;  to  pretend  that  he  is  well  he  looks 
around  at  the  scenery  or  into  shop  windows.  After 
a  few  minutes'  rest  he  is  able  to  crawl  on  again.  Going 
uphill  or  going  against  the  wind  is  especially  hard 
for  such  patients.  Any  emotion  —  fear,  anger  —  in 
the  arteriosclerotic  will  produce  the  same  pain  by 
making  the  heart  beat  violently. 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

There  are  many  causes  for  angina  pectoris,  but  arte- 
riosclerosis is  the  commonest  cause.  Angina  conies  in 
younger  people  from  nervous  causes  and  is  then  not  at 
all  serious.  But  when  angina  is  part  of  arteriosclerosis 
it  is  always  serious.  There  is  no  other  pain  in  the  trunk 
brought  on  by  emotion  or  exertion  and  relieved  by  rest. 

The  nights  are  very  bad  when  compensation  begins 
to  fail  in  any  type  of  heart  disease ;  and  for  years  the 
arteriosclerotic  may  have  bad  nights.  I  remember  a 
man  who  for  a  considerable  number  of  months  never 
lay  down  at  night,  but  slept  in  a  Morris  chair,  and  yet 
went  to  business  next  morning.  He  had  learned  to 
sleep  well  sitting  up.  In  late  stages  of  the  disease 
patients  are  often  more  or  less  delirious.  They  may  get 
out  of  bed  —  they  do  not  know  just  why;  or  they  are 
mildly  out  of  their  heads  during  the  night ;  and  yet  all 
right  again  in  the  daytime.  They  sometimes  go  back 
on  their  best  friends,  or  make  the  wrong  kind  of  a  will, 
because  their  brains  are  ill  nourished. 

The  nephritic  type  of  Heart  disease  is  that  which  comes 
on  as  the  result  of  kidney  disease.  Of  kidney  disease 
itself  I  shall  speak  later.  It  results  in  holding  back  in 
the  blood  poisonous  waste  products  which  should  be 
passed  out  by  the  urine.  Those  poisons,  as  they  circu- 
late in  the  blood,  stimulate  the  blood  vessels  around 
them  to  contract  upon  their  contents,  and  this  spasm 
produces  high  blood  pressure.  There  are  two  main 
eauses  of  high  blood  pressure  —  arteriosclerosis  and 

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DISEASES  OF  THE  HEART  AND  ARTERIES 

kidney  trouble:  arteriosclerosis  through  hardening  of 
the  arteries,  kidney  trouble  through  making  poisons 
circulate  in  the  arteries  and  stimulate  the  muscular 
fibres  in  the  arteries  to  close  in  upon  their  contents.  As 
a  result  of  high  blood  pressure  the  heart  has  to  work 
harder  and  harder  until  it  gives  out.  In  chronic  kidney 
trouble  failure  comes  in  about  eighteen  months  from 
the  patient's  earliest  complaint,  making  this  the  worst 
type  of  heart  disease  that  we  have. 

When  we  are  told  that  a  person  in  whom  we  are  in- 
terested has  heart  disease,  we  must  try  to  get  from  the 
doctor  a  diagnosis  including  a  prognosis.  That  will 
tell  us  which  type  of  heart  disease  we  are  dealing  with. 
The  different  types  are  entirely  different  propositions 
from  the  point  of  view  of  making  a  plan  for  the  patient. 
To  people  of  the  first  type,  patients  with  rheumatic 
heart  disease,  we  can  truthfully  say,  "You  must  try  to 
take  care  of  yourself  for  months  or  years ;  if  you  do  you 
will  have  a  good  chance  of  living  a  useful  and  happy 
life."  You  cannot  truthfully  say  this  to  people  with 
any  of  the  other  three  types  of  heart  trouble.  You  can 
say  to  people  of  the  arteriosclerotic  type,  that  with 
care  and  rest  they  will  live  along  fairly  comfortably 
for  some  years,  but  that  is  all.  The  syphilitic  type  is 
worse  and  the  nephritic  worst  of  all. 

The  treatment  of  all  types  of  heart  disease  is  rest  and 
digitalis,  plus  some  measures  which  empty  out  the 
dropsical  fluid  from  the  tissues.  It  is  really  miraculous 

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what  rest  can  do,  without  anything  else  at  all,  for  the 
rheumatic  types  of  heart  disease  after  compensation 
has  failed.  A  person  who  has  seemed  to  be  at  death's 
door  may  recover  and  live  for  many  years,  provided 
he  can  rest.  The  problem  of  rest  in  a  young,  active 
child  is  of  course  a  very  difficult  one,  and  I  do  not 
think  any  community  has  ever  considered  it  on  a  large 
scale.  We  take  the  problem  of  lung  disease  —  tuber- 
culosis —  very  seriously,  but  the  problem  of  heart 
disease,  which  is  far  larger  and  causes  just  as  many 
sufferings  and  deaths,  we  do  not  yet  take  seriously. 
The  ingenuity  of  the  social  worker,  in  providing  games, 
etc.,  may  save  the  life  of  the  child  in  rheumatic  heart 
disease,  by  keeping  it  quiet  for  months  at  a  time.  The 
doctor  may  be  powerless  and  the  mother  is  often  equally 
powerless.  But  the  social  worker  may  make  it  possible 
to  keep  the  child  quiet,  especially  if  she  uses  first-rate 
brains.  He  won't  stay  quiet  and  read  improving  books, 
but  he  will  sometimes  use  his  hands  on  something  of 
interest. 

Questions  and  Answers 

Q.  Are  cardiac  patients  to  be  forbidden  all  exercise? 

A.  No,  I  should  not  say  as  much.  They  should  do  no  work 
as  long  as  they  have  what  the  doctors  call  "acute  symptoms," 
which  are  fever,  short  breath,  dropsy,  cough,  and  scanty 
urine.  Later  they  are  better  for  taking  such  exercise  as  they  can 
take  without  getting  short  of  breath. 

Q.  Do  you  often  get  a  nervous  condition  as  a  result  of 
heart  trouble,  so  that  people  find  it  very  difficult  to  sit  still? 

A.  The  choreic  patient  is  in  exactly  that  condition;  he 

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DISEASES  OF  THE  HEART  AND  ARTERIES 

wriggles  all  the  time.  The  arteriosclerotic  is  often  very 
restless.  There  is  another  type  of  restlessness  (local  twitch- 
ings  about  the  face)  in  persons  who  are  merely  "nervous," 
because  they  always  were  so.  This  has  no  relation  to  heart 
trouble.  I  do  not  think  I  can  say  that  heart  disease  ever 
makes  a  person  restless.  Chorea  accompanies  heart  trouble, 
but  is  not  caused  by  it. 

Q.  In  talking  to  some  heart  cases  I  get  the  impression 
that  they  would  be  relieved  if  they  could  get  up  and  get 
about? 

A.  With  elderly  people  it  is  sometimes  almost  impossible 
to  insist  on  rest  in  bed.  They  have  a  constant  impulse  to  get 
their  feet  out  and  on  the  floor  and  sometimes  they  are 
content  then.  But  the  greatest  difficulty  of  keeping  people 
quiet  in  this  disease,  as  in  other  diseases,  is  that  idleness 
turns  the  mind  in  upon  one's  self.  This  is  bad,  of  course;  a 
cardiac  patient  can  get  neurasthenic  just  as  well  as  anybody 
else.  He  gets  to  counting  his  pulse  sometimes  and  then  is 
much  worse  off  than  if  he  had  not  been  trying  to  rest.  Doc- 
tors sometimes  have  to  steer  a  very  difficult  course  between 
making  a  neurasthenic  by  rest  and  breaking  compensation 
by  allowing  the  patient  to  work. 

Q.  When  does  arteriosclerosis  begin? 

A.  It  may  begin  at  any  age.  Congenital  syphilitics  may 
have  it  in  childhood,  but  it  generally  shows  itself  after  forty. 

Q.  Why  do  more  men  have  it  than  women? 

A.  Syphilis  is  probably  the  greatest  single  cause  of  arte- 
riosclerosis and  more  men  have  that  than  women.  Hard 
muscular  work  is  probably  a  contributing  cause,  and  men 
do  more  of  this  than  women.  Alcohol  is  a  contributing  cause, 
I  think,  in  syphilitic  cases.  All  these  three  causes  are  found 
in  men  more  often  than  in  women. 

Q.  How  does  worry  harm  a  person  with  heart  disease? 

A.  In  the  first  place,  by  preventing  sleep.  Of  course,  any- 
thing that  tires  a  person  tires  his  heart  also  by  disturbing  his 
compensation.  Moreover,  insomnia  injures  nutrition  and 

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the  heart  patient  needs  his  nutrition.  Again,  worry  raises 
blood  pressure,  and  in  the  cases  in  which  blood  pressure  is  a 
serious  feature  worry  thus  directly  adds  to  the  cause  of  the 
whole  trouble. 

Diseases  of  the  Arteries 

Arteriosclerosis  is  the  process  of  growing  old.  It  is 
not  the  cause  of  growing  old  —  it  is  growing  old.  We 
are  as  old  as  our  arteries.  A  person  of  sixty  may  have 
the  arteries  of  forty;  then  he  is  forty,  whatever  the 
calendar  says.  Arteriosclerosis  probably  begins  soon 
after  birth.  It  is  quite  distinct  at  twenty-one  in  the 
normal  person,1  and  goes  on  and  on  from  that  time. 
It  does  not  begin  to  do  obvious  harm  as  a  rule  until  the 
later  years  of  life,  and  in  many  cases  it  does  no  known 
harm  at  all.  As  it  affects  the  whole  arterial  tree  down 
to  its  smallest  twigs,  it  may  affect  any  organ  or  tissue  in 
the  body.  This  condition,  while  we  call  it  a  disease,  is 
a  very  queer  disease,  because  it  is  one  which  the  whole 
human  race  has  almost  from  birth.  The  sick  man 
merely  has  more  of  it  than  the  rest  of  us,  or  has  it  in 
a  more  serious  form,  or  in  a  more  serious  place  —  as  in 
the  brain,  or  in  the  arteries  of  his  heart.  If  he  had  the 
same  amount  of  trouble  in  the  arteries  of  his  leg  or  his 
arm,  it  might  do  no  harm,  but  in  the  heart  or  brain  it 
often  proves  fatal.  Hence,  in  the  apparently  chance 
distribution  of  the  amount  of  arteriosclerosis  here  or 

1  Thayer  and  Fabyan:  "Studies  on  Arteriosclerosis,  with  Special  Ref- 
erence to  the  Radial  Artery."  American  Journal  of  the  Medical  Sciences, 
1907,  vol.  134,  p.  811. 

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DISEASES  OF  THE  HEART  AND  ARTERIES 

there  in  the  body,  it  is  for  most  of  us  like  gray  hair,  with 
which,  but  not  because  of  which,  we  die.  In  others  it  is 
the  cause,  and  the  only  cause,  of  death. 

Merely  because  a  person  is  found  to  have  arterio- 
sclerosis, he  does  not  need  to  take  his  ailment  very  seri- 
ously. Elderly  people  hear  that  they  have  high  blood 
pressure  and  are  apt  to  be  terrified  for  fear  that  an 
artery  is  going  to  break.  But  in  fact  it  seldom  does. 
Having  arteriosclerosis,  even  having  high  blood  pres- 
sure, does  not  necessarily  mean  anything  serious.  It  is 
both  difficult  and  important  to  steer  the  right  course 
here  in  avoiding  both  anxiety  and  unpreparedness. 
Social  workers  should  help  physicians  to  explain  this 
disease  to  the  laity. 

Arteriosclerosis  of  the  brain  is  the  usual  cause  of 
apoplexy  or  cerebral  hemorrhage.  When  we  hear  that 
an  old  man  has  had  "a  stroke'*  or  "a  shock,"  the 
chances  are  that  he  has  had  arteriosclerosis  with  high 
blood  pressure  and  that  he  happened  to  have  a  weak 
spot  in  one  of  the  arteries  of  the  brain.  That  gives 
way,  the  blood  is  poured  out  into  the  brain,  and  the 
person  dies  or  is  paralyzed  on  one  half  of  the  body. 
Apoplexy  generally  recurs.  The  first  attack  is  usually 
not  fatal.  A  little  arterial  twig  gives  way,  but  the  blood 
is  absorbed,  the  person  recovers  partially  or  wholly; 
later  the  weak  branches  give  way  in  another  and  more 
serious  place.  In  the  brain,  arteriosclerosis  also  leads 
to  chronic  insanity  in  a  form  that  may  be  almost  indis- 
tinguishable from  paresis  or  dementia  paralytica. 

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Milder  cases  of  arteriosclerosis  in  the  brain  cause 
trouble,  —  some  attacks  of  dizziness,  sometimes  tran- 
sitory, unconsciousness,  speechlessness  or  paralysis. 
Vomiting  often  comes  with  these  attacks,  hence  the 
stomach  may  be  ^rongly  blamed. 

The  tendency  to  dizzy  spells  usually  passes  off  in  a 
year  or  two. 

Arteriosclerosis  in  the  heart  gives  us  the  type  of  heart 
disease  which  I  have  already  described,  with  or  without 
angina. 

Arteriosclerosis  of  the  kidney  gives  a  type  of  chronic 
kidney  trouble  which  leads  slowly,  not  rapidly,  to 
death. 

Very  often  we  have  all  these  three  forms  of  arterio- 
sclerosis at  once.  We  have  some  elements  of  arterio- 
sclerosis in  the  brain,  the  heart,  and  the  kidneys.  We 
may  hear  that  such  a  man  is  "breaking  up  all  over"  — 
a  general  breaking  up.  That  may  be  true. 

The  prognosis  of  arteriosclerosis  is  very  difficult  to 
state.  On  the  whole  I  think  people  usually  get  too 
much  worried  about  it.  Predictions  are  especially  dif- 
ficult because  the  disease  affects  different  parts  of  the 
arterial  tree  in  every  case.  One  can  have  it  for  forty  or 
fifty  years  and  feel  none  the  worse  for  it  because  it  does 
not  affect  a  vital  spot.  Another  with  much  less  trouble 
may  die  because  an  artery  in  the  heart  or  in  the  brain 
happens  to  be  affected. 

We  have  no  treatment.  We  do  not  want  to  see  pa- 
tients' time  or  money  spent  in  efforts  to  cure  that  for 

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DISEASES  OF  THE  HEART  AND  ARTERIES 

which  there  is  no  cure.  It  is  just  as  curable  as  gray  hair, 
and  it  may  do  as  little  harm.  When  it  affects  the  heart 
we  treat  it  by  digitalis,  rest,  and  relief  of  dropsy.  Diet 
has,  in  my  opinion,  no  considerable  effect.  But  most  of 
us  agree  in  restricting  meat  to  a  small  amount  once  a 
day  and  allowing,  otherwise,  most  ordinary  foods  in 
moderation.  Overeating  is  the  commonest  mistake  and 
most  people  know  when  they  have  overeaten  and  can 
stop  it  when  so  advised.  There  have  been  many  fads 
and  fancies  about  this  disease.  Metchnikoff's  sour- 
milk  treatment  is  the  best  known,  but  there  is  nothing 
in  it  to  the  best  of  my  knowledge. 

Aneurism 

The  only  other  important  disease  of  the  arteries 
is  aneurism.  Aneurism  is  usually  a  part  of  syphilitic 
heart  trouble.  The  big  arterial  tube  (the  aorta)  at  the 
top  of  the  heart,  turns  over,  goes  down  behind  the 
heart,  and  divides.  Syphilis,  when  it  hits  the  aorta,  for 
some  reason,  which  none  of  us  know,  hits  it  oftenest  in 
the  arch  just  where  the  turn  comes.  Syphilitic  aortitis, 
or  syphilitic  inflammation  of  the  aorta,  begins  there 
and  from  there  it  spreads  down  to  the  heart  valves, 
here  causing  the  type  of  trouble  that  I  have  described.1 
But  syphilitic  aortitis  also  weakens  the  walls  of  the 
aorta  so  that  it  bulges  out.  That  is  aneurism.  It  may 
become  as  big  as  a  child's  head  inside  the  chest,  press- 
ing on  surrounding  parts  and  causing  pain,  cough,  and 

1  See  page  70. 
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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

hoarseness.  The  danger  is  that  the  bulging  aorta  will 
rupture,  with  sudden  death  from  hemorrhage.  In  cases 
that  last  any  length  of  time,  that  is  what  happens, 
unless  the  patient  dies  of  some  other  disease  mean- 
time. 

The  disease  is  incurable  and  usually  runs  its  course 
within  two  years,  as  all  types  of  syphilitic  heart  disease 
do.  The  first  six  inches  of  the  aorta  is  the  only  impor- 
tant artery  where  one  has  aneurism.  There  are  little 
aneurisms  in  the  arteries  of  the  legs  and  arms,  most  of 
which  can  be  operated  upon  and  cured.  They  are  not 
syphilitic.  Aneurism  of  the  aorta  is  always  syphilitic. 
(Aneurism  of  the  heart  is  a  very  different  thing  and  is 
so  rare  that  I  shall  not  describe  it.) 

Varicose  Veins 

There  is  but  one  common  disease  of  the  veins,  vari- 
cose veins,  which  most  of  us  have  seen.  The  current  in 
the  veins  is  comparatively  slow.  In  the  arteries  it  is 
swift.  But  after  the  blood  reassembles  from  the  capil- 
lary sponge,  it  moves  slowly  and  it  has  an  unusually 
hard  time  going  uphill  from  the  legs  to  the  heart.  So 
we  see  varicose  veins  most  in  people  who  are  obliged  to 
stand  a  good  deal.  When  they  have  to  walk  a  good  deal, 
the  muscles  push  the  blood  along  in  the  veins,  but  in 
standing  the  veins  stretch  and  stretch  and  become 
curved  and  dilated,  which  is  what  the  word  varicose 
means:  just  as  a  river  like  the  Mississippi  becomes 
more  and  more  curved  as  time  goes  on. 

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DISEASES  OF  THE  HEART  AND  ARTERIES 

This  has  three  common  effects :  the  first  itching  and 
later  eczema  in  the  legs;  the  second  is  pain  and  swell- 
ing; the  third  is  chronic  ulcer  —  so-called  varicose  ulcer. 
(Rarely  a  vein  breaks  and  a  good  deal  of  blood  may  be 
thus  lost.)  We  see  many  of  these  cases  in  working 
people  and  among  hospital  out-patients.  The  bandag- 
ing of  varicose  ulcers  used  to  be  a  thing  which  surgical 
internes  dreaded  because  it  went  on  day  after  day  and 
week  after  week  and  its  advantages  were  hard  to  see. 
That  is  all  wrong  and  unnecessary.  The  difficulty  is  to 
persuade  the  patient  and  sometimes  the  surgeon  that 
these  ulcers  can  be  cured  by  an  operation,  dissecting 
out  the  veins.  What  happens  then?  The  answer  is  that 
we  have  a  great  many  more  veins  than  we  have  use  for, 
so  that  when  one  set  is  cut  out,  another  set  takes  up  the 
blood  and  the  person  has  better  circulation  than  he 
had  before.  Nature  has  been  profuse  with  veins,  and 
by  one  of  the  wonderful  processes  of  compensation,  the 
small  veins  can  enlarge  and  take  up  the  blood  formerly 
carried  by  the  diseased  vessels. 

The  cure,  then,  is  operation.  The  palliative  treat- 
ment is  rest,  keeping  the  feet  up  so  that  the  force  of 
gravity  does  not  add  to  the  stagnation ;  also  bandag- 
ing with  flannel  bandages.  In  my  student  days  I  said 
so  often  to  patients  with  varicose  ulcer  that  I  could  say 
it  in  my  sleep,  "Buy  a  yard  of  flannel,  cut  it  three 
inches  wide  on  the  bias,  and  sew  the  ends  together. 
Then  wind  it  round  the  leg  from  below  up."  The  point 
of  cutting  it  on  the  bias  is  that  you  get  more  elasticity 

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in  that  way.  These  flannel  bandages  are  useful  pallia- 
tives for  people  who  cannot  or  will  not  be  operated 
upon.  They  support  the  veins  and  so  sometimes  pre- 
vent the  development  of  ulcer. 

Ulcer  develops  because  the  nutrition  is  so  poor ;  the 
blood  not  flowing  on  as  it  should,  the  part  becomes 
poorly  nourished ;  then  an  ulcer  forms  and  often  stays 
for  years. 

It  is  important  not  to  confound  this  ulcer  with  syphi- 
litic ulcer.  There  are  a  great  many  syphilitic  ulcers  on 
the  lower  legs,  and  social  workers  are  apt  to  assume 
that  all  chronic  ulcers  on  the  leg  are  syphilitic,  thereby 
doing  some  people  a  great  injustice.  The  distinction 
rests  on  the  situation  of  the  ulcer,  on  the  Wassermann 
reaction,  and  on  the  evidence  of  the  twisted  veins  in  the 
non-syphilitic  varicose  cases. 

Questions  and  A  nswers 

Q.  Do  diseases  of  the  heart  have  anything  to  do  with  vari- 
cose veins? 

A.  No.  A  person  might  have  both  diseases,  but  I  do  not 
think  there  is  any  connection. 

Q.  What  is  the  connection  between  cough  and  heart 
disease? 

A.  When  the  heart  does  not  pump  properly,  there  is 
stagnation  in  the  lungs,  stagnation  of  the  blood  which  the 
heart  should  send  through  swiftly.  Stagnation  results  in  the 
blood's  oozing  through  the  walls  of  the  blood  vessels  in  the 
lungs.  Close  around  these  blood  vessels  are  the  air  spaces, 
which  get  filled  up  by  this  fluid  part  of  the  blood,  called 
serum.  This  serum  has  then  to  be  coughed  out.  It  is  not 
mucus,  though  it  may  be  coughed  up  with  mucus. 

82* 


DISEASES  OF  THE  HEART  AND  ARTERIES 

Q.  What  is  the  social  worker  to  do  when  a  physician 
wants  a  child  treated  for  mitral  regurgitation? 

A.  I  should  say  that  we  should  find  out  by  questioning  the 
doctor  whether  the  child  has  good  compensation  or  bad.  If  he 
has  good  compensation,  he  is  to  be  allowed  to  do  everything 
that  other  children  do  except  in  so  far  as  he  gets  out  of 
breath.  He  can  play  baseball  so  long  as  he  does  not  pitch  or 
run  the  bases.  If  the  condition  is  uncompensated,  he  is  tcTBe 
put  to  bed  until  compensation  returns. 


CHAPTER  IV 

DISEASES   OF   THE   GASTROINTESTINAL   TRACT 

THE  mouth  is  the  first  part  of  the  gastro-intestinal 
tract.  In  the  mouth  we  encounter  at  once  a  burning 
question  over  which  the  majority  of  people  and  doctors 
are  in  doubt  at  the  present  time  —  that  is,  the  jm-^ 
portance,of  the  teeth  and  the  diseases  of  the  teeth  in 
relation  to  troubles  in  other  parts  of  the  body. 

There  are  three  disturbances  of  the  teeth  to  which 
importance  is  attached,  rightly  or  wrongly,  by  physi- 
cians and  dentists,  as  causes  of  diseases  at  a  distance 
from  the  mouth :  — 

(i)  Riggs'  Disease,  of  which  the  Latin  name  is  pyor- 
rhea  alveolar  is.  (It  is  well  to  learn  as  fast  as  we  can  these 
roots  of  which  the  words  of  medicine  are  made  up.  Pyo 
always  means  pus,  as  in  pyopneumothorax,  pyosalpinx, 
etc.  Wherever  rrhea  occurs,  it  means  a  running,  a  dis- 
charge, as  in  gonorrhea,  otorrhea,  leucorrhea.  Pyorrhea 
in  itself  simply  means  a  discharge  of  pus.  Pyorrhea 
alveolar  is  means  a  running  of  pus  from  the  jaw,  the 
alveolar  process  as  the  jaw  is  called  in  anatomy.) 

This  is  a  disease  ordinarily  of  people  in  middle  life 
or  older.  The  gums  retract,  uncovering  the  upper  por- 
tions of  the  teeth ;  pus  forms  under  the  gum  and  is  con- 
stantly discharged.  This  is  an  enormously  common  dis- 

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THE  GASTROINTESTINAL  TRACT 

ease.  Sometimes  it  seems  as  if  everybody  over  forty 
had  it.  No  one  knows  the  cause  of  it.  It  has  been  vigor- 
ously maintained  within  a  year  that  we  had  found  the 
cause  in  a  particular  amoeba,  but  that  has  been  dis- 
proved, and  I  think  it  is  safe  to  say  to-day  that  no- 
body knows  the  cause  of  pyorrhea.  In  my  opinion  it  is 
not  a  serious  disease  except  locally,  and  is  very  seldom 
if  ever  the  cause  of  disease  anywhere  else  in  the  body. 
It  is  a  bother,  and  it  is  dangerous  from  the  point  of  view 
of  the  teeth  themselves,  but  I  think  there  is  very  little 
evidence  that  it  harms  us  elsewhere. 

The  point  which  we  need  to  understand,  with  this 
as  with  many  other  pus  processes  in  the  body,  is  that 
everything  depends  upon  our  powers  of  resistance.  The 
mere  presence  of  bacteria  means  nothing  and  does  not 
constitute  disease.  Disease  is  the  presence  of  these  bac- 
teria plus  our  lack  of  resistance  to  them.  For  example, 
we  have  all  of  us,  all  the  time,  bacteria  in  the  deeper  lay- 
ers of  our  skin.  We  cannot  wash  them  off  —  they  are 
too  deep  in.  But  when  our  vitality  is  reduced,  they 
produce  a  pimple  or  some  other  disease  in  the  skin. 
Bacteria  are  always  present  in  the  mouth  also,  and  are 
harmless  until  we  get  debilitated.  Then  they  may  pro- 
duce inflammation  in  the  throat  or  in  the  lungs.  There 
are  bacteria  passing  through  the  kidneys  all  the  time. 
If  anything  reduces  our  general  health,  they  take  root 
and  produce  trouble  there.  The  presence  of  bacteria  in 
itself  never  causes  disease.  An  enthusiastic  dentist  or 
some  one  else  says,  "How  can  it  help  being  unhealthy 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

to  have  all  this  pus  in  your  mouth?"  But  how  can  it 
be  healthy  to  have  all  those  millions  of  bacteria  in 
our  intestine?  —  yet  apparently  we  not  only  tolerate 
but  need  them.  So  far  as  we  know  they  are  a  neces- 
sary element  in  the  process  of  digestion.  They  live 
with  us,  not  on  us,  and  help  us  to  live. 

(2)  Caries  of  the  teeth  is  the  well-known  decay,  for 
which  fillings  in  the  teeth  are  made ;  when  it  penetrates 
deeper,  it  results  in  many  of  the  abscesses  about  the 
roots  of  the  teeth,  and  probably  in  the  death  of  the 
teeth.  It  is  a  very  different  process  from  pyorrhea, 
which  is  on  the  outside  and  under  the  gum.  Caries 
penetrates  deeply  into  the  teeth.  Again  I  think  it  can 
be  said  that  no  one  knows  the  cause  of  it.  It  could  not 
go  on  without  bacteria,  but  the  presence  of  bacteria  in 
itself  is  not  enough  to  cause  it.  It  is  practically  univer- 
sal. Those  who  examine  children  in  the  public  schools 
can  find  nearly  one  hundred  per  cent  of  "  physical  de- 
fects "  by  noting  all  the  caries  in  their  teeth  and  in 
calling  all  caries  a  "defect." 

The  one  point  of  interest  for  us  all,  I  think,  is  that 
pus  pockets  about  the  teeth  certainly  may  be  the  cause 
of  disease  outside  the  mouth.  The  sole  interesting 
question  is  how  and  when  and  how  often  they  are  the 
cause  of  disease  outside  the  mouth.  In  many  cases, 
certainly,  they  exist  harmless  for  years,  producing  no 
symptoms  whatever.  Simply  because  the  X-ray  man 
finds  a  pocket  or  two  about  tooth  roots,  that  is  no 
reason  for  having  them  treated.  It  is  for  a  sensible 

86 


THE  CASTRO-INTESTINAL  TRACT 

and  expert  dentist  to  decide  whether  there  is  any  rea- 
son for  operating  on  that  pus  pocket. 

The  main  diseases  due  to  such  pus  pockets  are  dis- 
eases of  the  joints,  which  are  often  called  rheumatism. 
Acute,  painful  disease  of  many  joints  may  be  caused 
by  pus  pockets  about  the  teeth,  or  by  pus  in  any  one 
of  a  good  many  other  situations.  The  more  important, 
besides  the  teeth,  are  the  tonsils,  the  antrum  (inside 
the  cheek  bone) ,  and  the  genito-urinary  tract ;  less  im- 
portant are  the  inner  ear,  and  possibly  —  not  probably 
—  the  intestine.  If  a  person,  then,  has  an  inflamma- 
tion of  many  joints,  an  acute  rheumatism,  and  no  other 
cause  is  found  except  pus  pockets  about  the  teeth,  it  is 
well  to  have  those  pus  pockets  cleaned  up.  That  is  as 
far  as  I  am  yet  willing  to  go.  Some  doctors  believe 
that  appendicitis,  stomach  ulcer  and  gall  bladder  dis- 
ease are  often  due  to  streptococci  coming  from  the 
tonsils  or  the  teeth. 

Fever,  without  joint  trouble,  may  be  produced  in 
the  same  way,  by  pus  about  the  roots  of  the  teeth.  If  a 
fever  exists  and  no  cause  can  be  found  for  it,  other 
than  these  pus  pockets  about  the  teeth,  they  should  be 
attended  to. 

(3)  There  has  been  a  good  deal  said,  I  think  with- 
out any  good  reason,  of  late  years,  about  dental  dis- 
eases as  a  cause  of  mental  and  nervous  disturbances: 
especially  by  an  enthusiast  in  Buffalo  who  has  main- 
tained that  pretty  much  all  insanity  is  due  to  diseases 
of  the  teeth,  particularly  a  third  form  of  disease,  im- 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

parted  or  unerupted  teeth  behind  the  other  teeth, 
whence  they  have  never  come  down.  An  X-ray  shows 
these  in  a  good  many  people,  and  if  we  photograph 
enough  of  such  people  we  find  among  them  some  who 
have  nervous  or  mental  disturbances.  I  do  not  think 
we  have  any  good  authority  for  believing  that  any 
diseases  of  the  teeth,  whether  pyorrhea,  caries,  or 
impacted  teeth,  are  connected  with  mental  disease. 

I  think  all  this  is  important,  because  we  often  hear 
of  people  who  have  been  urged  to  go  to  considerable 
expense  and  trouble  in  the  hope  of  getting  a  new  lease 
of  life  out  of  dental  work,  which  will  not  give  them  any 
new  lease  of  life,  but  only  better  teeth.  It  should  be 
said  that  all  the  problems  about  the  teeth  which  I  have 
presented  here  are  still  new  problems,  and  still  open  to 
discussion,  but  I  think  discussion  is  crystallizing  pretty 
fast. 

Emetin,  which  is  the  active  principle  of  our  old 
friend  ipecac,  is  given  subcutaneously  for  many  dis- 
eases caused  by  amoebae,  especially  dysentery;  it  is 
also  effective  in  killing  amoebae  in  the  mouth.  We 
have  an  enormous  number  of  amoebae  (an  amoeba  is  an 
animal,  not  a  bacillus  properly  so  called)  in  our  mouths, 
but  it  is  not  yet  proved  that  they  do  any  harm.  Some 
people  think  they  do  good  as  scavengers,  serving  us  as 
the  scavenger  serves  society.  Emetin  will  kill  these 
amoebae,  but  it  is  yet  to  be  proved  that  it  does  us  any 
service  by  killing  them.  Emetin  is  a  valuable  drug 
for  a  good  many  purposes;  but  it  is  still  a  new  drug 

88 


THE  GASTROINTESTINAL  TRACT 

and  has  dangers  because  no  one  knows  exactly  its  ca- 
pacities for  poisoning.  It  should  never  be  used  except 
under  direction  of  a  physician  who  knows  all  about  its 
use  and  the  particular  brand  used. 

There  are  certain  other  questions  about  the  teeth 
that  concern  general  medicine.  It  has  been  believed 
that  bad  teeth  are  often  the  cause  of  dyspepsia.  Ten 
years  ago  I  often  heard  physicians  say,  "Of  course  he 
has  dyspepsia;  he  has  no  teeth;  how  can  he  chew  his 
food?"  Now  we  almost  never  hear  that.  "Oh,  yes,  I 
can  gum  it .1!  a  toothless  old  man  says  to  me  every  now 
and  then,  and  they  do  gum  it  perfectly  well.  I  think 
the  time  when  teeth  were  thought  to  be  so  indispensa- 
ble was  the  time  when  we  thought  that  meat  was  in- 
dispensable in  the  diet  of  adults.  Almost  the  only 
thing  we  need  teeth  for  is  meat,  and  if  meat  is  seen  to 
be,  as  it  is  now,  an  unimportant  article  of  diet  for 
adults,  the  question  of  chewing  is  not  so  important. 
Soft  foods  can  be  chewed  without  teeth.  If  children's 
jaws  are  so  tender  from  bad  teeth  that  they  cannot 
chew,  they  will  suffer,  but  I  cannot  say  that  I  have 
ever  seen  a  child  with  dyspepsia  or  indigestion  or  mal- 
nutrition because  of  bad  teeth.  I  think  the  evidence 
goes  to  show  that  the  sequence  is  the  other  way  —  they 
have  bad  teeth  because  they  are  not  nourished. 

I  have  yet  to  see  that  the  teeth  have  any  importance 
in  relation  to  tuberculosis.  The  germs  of  tuberculosis 
have  been  found  in  teeth  and  in  the  pus  pockets  of 
alveolar  abscesses,  but  that  they  have  any  important 

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relation  to  tuberculosis  I  do  not  think  is  as  yet  shown, 
and  I  do  not  think  it  is  the  opinion  held  by  competent 
authorities.  Please  note  before  we  leave  this  subject 
that  I  have  spoken  of  the  teeth  wholly  in  relation  to 
diseases  outside  the  mouth.  About  dental  disease  and 


• 
I  • 


t?4 

' 


its  effects  on  the  teeth  themselves  I  am  not  competent 
to  speak  and  make  no  attempt  to  speak.  I  am  not  un- 
dervaluing the  care  of  the  teeth  for  the  teeth's  sake 
and  to  avoid  toothache. 

Before  I  leave  this  subject  I  should  speak  of  the  so- 
called  "  Hutchinsonian  "  teeth,  the  teeth  of  congenital 
syphilis.  There  is  no  absolutely  pathognomonic  or  ab- 
solutely certain  form  of  syphilitic  teeth,  but  the  teeth 

90 


THE  GASTRO-INTESTINAL  TRACT 

which  are  especially  concerned  in  this  question  of  con- 
genital syphilis  are  the  two  central  upper  incisors. 
These  two  teeth  normally  are  at  least  as  broad  at  the 
cutting  edge  as  they  are  at  the  gum,  sometimes  a  little 
broader.  In  contrast  with  that,  in  the  teeth  of  congen- 
ital syphilitics  these  central  incisors  slant  in  so  that 
they  are  narrower  at  the  cutting  edge  than  at  the  gum. 
They  also  are  often  notched  on  the  edge,  but  the  notch 
is  not  the  essential  thing.  The  essential  thing  is  the 
lateral  slanting  in  toward  the  cutting  edge.  Do  not 
suspect  any  one  because  you  find  a  notch  in  the  edge  of 
the  teeth.  Do  not  suspect  any  one  because  some  tooth 
narrows  laterally  toward  its  cutting  edge.  But  we  may 
suspect  syphilis  if  the  upper  central  incisors  slant  in 
from  the  sides.  See  Fig.  28.  Jonathan  Hutchinson 
described  these  teeth  many  years  ago,  and  they  are 
called  "  Hutchinsonian  "  on  account  of  him. 

It  is  not  always  necessary  to  have  anything  done  for 
decayed  teeth  in  order  to  improve  patients*  general 
health.  That  is  a  question  for  careful  study  and  not 
for  a  decision  at  first  hand.  I  have  seen  a  great  number 
of  perfectly  healthy  persons  who  have  had  bad  teeth 
all  their  lives. 

We  are  sometimes  asked :  Should  not  all  tuberculosis 
patients  have  their  teeth  attended  to  at  the  outset  of 
treatment?  I  do  not  think  so.  It  should  depend  on  how 
bad  their  teeth  are  and  what  symptoms  they  have  that 
might  be  attributed  to  their  teeth. 

I  am  talking  wholly  about  health  and  not  about 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

beauty.  It  is  very  hard  to  break  down  one  of  the  most 
untrue  statements  ever  made,  that  cleanliness  is  next 
to  godliness.  The  poor  who  are  dirty  are  at  least  as 
godly  as  the  rich  who  are  clean.  Granted  that  to  have 
perfect  teeth  a  person  must  have  them  attended  to 
whenever  there  is  any  disease  in  them,  this  is  not  for 
fear  of  nervousness,  indigestion,  insanity,  or  dyspepsia. 
Doubtless,  if  all  teeth  were  perfectly  taken  care  of  for 
their  own  sake,  other  diseases  —  for  example,  joint 
troubles — would  be  less  likely  to  come.  But  you  might 
take  care  of  a  thousand  persons'  teeth  to  save  one  joint. 

The  tongue  is  an  organ  seldom  diseased,  but  there  are 
three  important  diseases  which  occasionally  occur  on 
the  tongue,  the  possibility  of  which  I  think  every  one 
should  know.  A  chronic  ulcer  or  sore  upon  the  tongue 
may  be  due  to  four  causes:  the  important  ones  are 
cancer,  tuberculosis,  syphilis;  the  unimportant  one  is 
jagged  teeth  in  the  vicinity,  which  keep  up  an  irrita- 
tion. The  diagnosis  between  those  three  important 
diseases  is  very  difficult.  I  myself  am  quite  unable  to 
make  it,  and  I  say  that  in  order  to  impress  the  fact 
that  any  person  who  has  a  chronic  sore  on  the  tongue 
should  have  the  most  expert  opinion  before  it  can  be 
known  whether  it  is  curable  by  anti-syphilitic  treat- 
ment, whether  it  is  due  to  a  tuberculous  process,  or 
whether  it  is  a  cancer  that  must  be  operated  on.  Diag- 
nosis is  hard,  but  it  can  be  and  should  be  made,  as  it  is 
of  great  importance  to  the  patient. 

The  throat.  I  have  discussed  tonsillitis  in  connection 

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THE  GASTRO-INTESTINAL ,  TRACT 

with  the  respiratory  diseases.  Syphilis  of  the  throat 
should  be  mentioned.  The  throat  is  one  of  the  com- 
moner places,  next  to  the  skin,  for  syphilis  to  appear.  It 
makes  a  chronic  ulceration,  extraordinarily  free  from 
pain  —  not  altogether  free,  but  wonderfully  near  to 
being  free  considering  how  extensive  the  ulceration  is. 
This  ulceration  is  usually  on  the  tonsil  or  on  the  soft 
palate.  Not  infrequently  it  perforates  the  soft  palate 
and  leaves  a  hole.  In  other  cases  it  makes  the  palate 
stick  to  the  back  of  the*  throat  so  that  discharges 
from  the  nose  can  hardly  go  down.  Syphilis  occasions 
trouble  in  breathing  in  the  larynx  lower  down,  which  I 
have  already  mentioned  in  connection  with  the  respira- 
tory diseases. 

The  treatment  is  the  same  as  the  treatment  of  syphi- 
lis anywhere  else.  The  outlook  also  is  good.  Processes 
in  the  throat  which  look  hopeless,  they  are  so  large  and 
angry,  will  disappear  under  proper  treatment. 

The  esophagus  or  gullet  is  the  next  step  down  the  in- 
testinal tube.  In  the  esophagus  there  are  very  few  dis- 
eases, practically  but  two  that  we  are  likely  to  see — 
cancer  and  corrosive  stricture.  Cancer  at  the  lower  end 
of  the  esophagus,  just  where  the  esophagus  joins  the 
stomach,  is  a  fairly  common  disease  and  manifests  it- 
self by  shutting  up  that  tube  so  that  people  cannot 
swallow,  or  can  swallow  only  liquids.  It  is  absolutely 
incurable,  and  all  that  can  be  done  is  to  stretch  this 
narrowing,  or  to  make  by  an  operation  an  opening  into 
the  stomach  so  that  we  can  feed  the  person  through  the 

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abdominal  wall.  This  may  keep  him  alive  for  a  year  or 
two,  but  the  disease  goes  on  just  the  same.  This  is  one 
of  the  places  where  cancer  is  most  hopeless ;  so  far  as  I 
know  there  is  not  a  chance  of  cure.  I  want  to  warn 
laymen  against  the  dangers  of  an  instrument  which 
is  sometimes  used  in  the  diagnosis  of  this  disease,  the 
esophagoscope,  an  instrument  for  seeing,  with  a  system 
of  mirrors,  directly  into  the  lower  end  of  the  esophagus. 
In  the  hands  of  an  expert  it  is  valuable,  in  the  hands  of 
any  one  else  very  dangerous.  I  have  known  patients 
to  die  as  the  result  of  having  this  instrument  unskil- 
fully used  for  diagnostic  purposes. 

Corrosive  stricture  of  the  esophagus  is  due  to  acids  or 
alkalis  swallowed  by  mistake.  The  strong  alkalis  used 
in  laundry  work  now  and  then  get  swallowed,  and  pro- 
duce an  inflammation  in  the  esophagus,  the  scar  of 
which  closes  the  esophagus.  These  cases  sometimes  live 
for  years  with  a  gastric  fistula  (an  opening  through  the 
abdomen  into  the  stomach).  One  such  case  has  gone 
on  for  twenty  years  and  may  go  on  for  many  more. 
Through  the  opening  made  by  the  surgeon  they  can  be 
fed  directly  into  the  stomach  without  using  the  mouth 
or  esophagus  —  a  little  inconvenient,  but  not  much. 

Spasmodic  stricture  of  the  gullet  at  its  entrance  to 
the  stomach  produces  a  stoppage  of  food  without 
known  cause,  gradually  increasing  year  by  year  until 
almost  no  food  will  go  down.  It  begins  usually  in  early 
adult  life.  It  is  cured  by  dilatation  of  the  stricture  with 
appropriate  instruments. 

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THE  GASTRO-INTESTINAL  TRACT 

The  stomach  is  a  region  interesting  to  most  persons 
because  of  their  personal  experiences  with  trouble 
there,  and  yet  it  is  true  that  real  organic  disease  of  the 
stomach  is  rare.  Stomach  symptoms  are  almost  uni- 
versal. Stomach  diseases  are  rare.  There  are  practi- 
cally only  two  diseases  of  the  stomach,  cancer  and 
ulcer.  The  other  diseases  which  manifest  themselves  by 
stomach  symptoms  will  be  discussed  later. 

I  will  deal  first  with  cancer  of  the  stomach.  The 
history  of  this  disease  is  one  which  I  think  we  should 
all  know  somewhat  in  detail,  because  the  diagnosis 
depends  so  much  upon  history.  When  the  diagnosis 
depends  largely  upon  the  history,  the  layman  and  the 
social  worker  should  know  it.  When  it  depends  on 
physical  examination,  it  is  of  course  wholly  the  business 
of  the  physician.  The  following  history  is  typical:  A 
person  over  forty-five,  who  has  had  no  previous  stomach 
trouble,  but  really  seems  often  to  have  been  particu- 
larly immune  to  stomach  trouble,  begins  suddenly  to 
have  dyspepsia,  "dyspepsia"  being  here  used  as  the 
general  word  for  any  kind  of  discomfort  or  pain  in  the 
region  of  the  stomach.  These  people  often  use  expres- 
sions like,  "  I  could  eat  shingle  nails  up  until  last  May.*' 
They  are  often  "gastric  athletes"  as  the  Germans  say, 
up  to  the  time  when  the  cancer  attacks. 

The  symptoms  of  gastric  cancer,  then,  begin  sud- 
denly in  a  person  who  has  had  no  stomach  trouble,  and 
never  stop.  The  distress  and  pain  that  he  has  come 
after  food,  and  are  often  the  cause  of  vomiting.  He 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

emaciates  rapidly.  On  that  history  in  an  elderly  person 
most  of  us  would  strongly  suspect  gastric  cancer,  no 
matter  what  physical  examination  showed  or  did  not 
show.  Physical  examination  may  show  something.  It 
may  show  a  lump  in  the  pit  of  the  stomach;  usually 
it  does  not.  X-ray  examination  is  of  great  value  in 
diagnosis. 

Gastric  cancer  usually  kills  in  from  one  to  three 
years.  In  a  general  way  it  may  be  said  that  it  is  in- 
curable. I  have  not  known  in  the  Massachusetts  Gen- 
eral Hospital  a  cure;  in  the  Mayo  Clinic  they  think 
they  have  had  some  cures.  Operation  is  performed  for 
relief  and  perhaps  with  some  hope  of  cure.  Cancer  is 
usually  at  the  lower  end  of  the  stomach  and  blocks  the 
outlet  more  or  less  completely,  so  that  food  stagnates 
in  the  stomach.  The  stomach  becomes  stretched,  or 
"  dilated,"  and  food  eaten  twenty-four  hours  or  even 
forty-eight  hours  before  may  be  recognized  in  what 
comes  up  during  vomiting.  In  health  the  stomach 
empties  itself  inside  of  eight  hours. 

The  operation  that  is  ordinarily  done  is  the  opera- 
tion of  gastroenterostomy.1  We  make  a  mouth  or  a 
connection  between  the  stomach  and  the  intestines, 
joining  them  so  that  the  food  goes  straight  from  the 
middle  of  the  stomach  into  the  intestine  and  does  not 
have  to  go  out  through  the  outlet  of  the  stomach,  now 
partially  blocked  by  the  cancer.  The  new  opening 

1  The  roots  joined  together  in  this  word  are  gastro,  stomach;  enter,  in- 
testines; stoma,  mouth. 


THE  GASTRO-INTESTINAL  TRACT 

works  perfectly  well,  and  if  it  were  not  for  the  cancer, 
would  cure.  But  the  cancer  spreads  and  soon  kills. 

Peptic  ulcer  is  a  much  more  manageable  affair  than 
cancer,  which  is  lucky  because  it  is  much  more  common. 
Here  again  the  history  is  important,  and  I  shall  go 
into  it  in  detail.  Notice  the  striking  contrasts  with  a 
cancer  history.  Peptic  ulcer  has  usually  been  going  on 
at  least  ten  years  when  a  doctor  first  hears  of  the  case. 
The  patients  average  about  forty-two  years  old  when 
one  first  sees  them,  but  they  have  often  had  the  disease 
since  they  were  twenty.  They  have  had  it  intermit- 
tently,  with  long  periods  of  perfect  health  —  no  trouble 
whatever  for  weeks,  months,  or  even  years. 

There  is  a  series  of  attacks  extending  over  a  long 
period  of  years.  Each  attack  is  essentially  as  follows: 
When  the  stomach  begins  to  be  empty,  two,  three,  or 
four  hours  after  a  meal,  the  patient  begins  to  be  con- 
scious of  distress,  which  varies  all  the  way  from  simple 
hunger,  through  discomfort,  to  active  pain.  The  most 
characteristic  thing  about  this  distress  is  not  its  nature 
as  a  sensation,  but  (<z)  the  fact  that  it  comes  when  the 
stomach  is  empty,  and  (b)  the  manner  of  its  relief.  It 
is  relieved  by  food.  The  taking  of  food  after  a  little 
while  removes  the  distress,  and  the  patient  is  comfort- 
able again  until  three  or  four  hours  later,  when  the 
stomach  is  again  empty.  It  is  also  relieved  by  any  al- 
kali, the  most  familiar  being  sodium  bicarbonate,  or 
cooking  soda;  also  by  vomiting,  or  by  washing  the 
stomach  out  with  the  stomach  tube.  There  are  then 

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four  methods  of  relief:  (i)  food,  (2)  alkali,  (3)  vomit- 
ing, (4)  washing  the  stomach. 

The  appetite  is  splendid  and  the  tongue  is  clean. 
These  symptoms  last  for  a  variable  period,  and  then, 
as  I  have  said,  disappear  and  recur  later. 

This  chain  of  symptoms  does  not  prove  ulcer,  it  only 
suggests  it.  They  may  be  due  simply  to  hyperacidity 
—  too  much  acid  —  without  ulcer,  and  that  distinction 
can  only  be  made  by  the  X-ray.  The  typical  history, 
plus  X-ray  findings,  means  ulcer.  The  typical  history, 
minus  X-ray  findings,  may  be  only  hyperacidity. 

The  more  we  talk  with  chronic  dyspeptics,  the  more 
we  find  their  symptoms  are  those  of  ulcer  or  of  hyper- 
acidity. This  is  the  common  chronic  dyspepsia.  If  we 
do  not  cross-question  them,  they  will  simply  say  that 
they  have  pain  after  food ;  which  is  true,  but  only  half 
true.  Their  pain  is  at  a  considerable  distance  after 
food  and  is  relieved  by  food?-  so  that  the  patient  often 
carries  crackers  in  his  pocket.  In  cancer  the  pain  comes 
immediately  after  food,  and  is  made  worse  by  putting 
food  into  the  stomach. 

The  ulcer  is  called  peptic  because  it  seems  to  be  the 
result  of  a  self-digestion  of  an  unsound  area  of  the  stom- 
ach. I  think  it  is  worth  while  to  stop  a  moment  and 
notice  what  an  extraordinary  thing  it  is  that  the  stom- 
ach does  not  always  digest  itself.  Take  the  stomach 
of  an  animal  and  put  it  into  the  gastric  juice  of  that 
animal,  and  it  will  be  digested  in  a  short  time.  We  ex- 
plain our  stomach's  ordinary  freedom  from  self-diges- 

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THE  GASTRO-INTESTINAL  TRACT 

tion  by  saying  that  the  stomach  is  alive.  As  long  as  it 
is  alive  its  own  gastric  juice  cannot  digest  it,  but  we  do 
not  know  what  that  means.  It  protects  itself  in  some 
way.  When  local  death  occurs  anywhere  in  the  stomach 
(perhaps  from  streptococcus  infection),  self-digestion 
begins,  and  a  round  hole  is  eaten  out  of  the  stomach  by 
its  own  juice,  until,  if  the  corrosion  goes  on  long  enough, 
it  may  actually  perforate  into  the  peritoneal  cavity 
producing  virulent  peritonitis.  This  is  an  occasional 
cause  of  sudden  death,  death  within  a  day  or  two. 

The  ulcer  usually  comes  within  an  inch  or  two  above 
or  below  the  pylorus  (the  ring  separating  the  stomach 
from  the  intestine).  It  is  essentially  the  same  disease, 
whether  in  the  last  inch  of  the  stomach  (gastric  ulcer) 
or  in  the  first  inch  of  the  duodenum  (duodenal  ulcer). 
In  about  one  fifth  of  the  cases  blood  in  large  amounts 
is  vomited,  or  passed  by  the  bowel.  This  is  bleeding 
from  the  floor  of  the  ulcer. 

The  treatment  of  this  trouble  is  either  medical  or 
surgical,  but  every  one  agrees  now,  I  think,  that  medi- 
cal treatment  should  be  tried  first,  and  surgical  treat- 
ment resorted  to  if  medical  fails.  Medical  treatment 
means  diet,  rest,  and  alkalis.  The  essentials  of  the 
diet,  which  I  do  not  mean  to  go  into  in  detail,  are  the 
cutting  out  of  meat  and  fish.  At  the  beginning  the 
patient  is  fed  substantially  on  milk  and  some  cereal 
such  as  crackers;  later  one  article  after  another  is 
added.  > 

Sometimes  the  ulcer  will  not  heal  in  spite  of  months 

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of  rest  and  diet  and  alkali.  Alkali  is  given  for  the  re- 
lief of  pain ;  it  does  not  cure  the  disease,  but  is  a  great 
comfort.  There  is  no  limit  to  the  amount  of  alkali  a 
patient  can  safely  take.  He  can  take  barrels  without 
doing  any  harm,  but  of  course  it  is  a  symptomatic  or 
palliative  treatment,  whereas  persistent  diet  and  rest 
do  give  us  hope  of  healing  the  ulcer. 

If  now  the  ulcer  will  not  heal,  the  surgeon  tries  to  cut 
out  the  ulcer,  and  in  any  case  does  gastroenterostomy 
or  some  more  extensive  operation.  That  is  sometimes 
curative,  and  almost  always  relieves.  The  gastric  con- 
tents do  not  then  any  longer  go  over  the  ulcer.  This  is 
often  a  most  insignificant  little  ulcer,  but  it  does  not 
heal  because  the  corroding  acid  contents  of  the  stom- 
ach bathe  it  three  times  a  day.  After  operation  it  may 
heal. 

Question'  and  Answer 

Q.  How  is  the  X-ray  examination  made? 

A.  The  ordinary  bismuth  salt,  subnitrate  of  bismuth,  is 
opaque  to  X-rays.  The  patient  swallows  a  glass  of  gruel 
which  contains  .from  one  to  four  ounces  of  bismuth.  It  does 
not  taste.  The  bismuth  coats  the  inside  of  the  stomach  and 
intestine,  and  when  the  X-ray  is  turned  on  we  see  the  stom- 
ach and  intestine  outlined  by  bismuth.  The  surface  of  the 
ulcer  is  irritable  and  will  not  bear  the  bismuth.  Hence  one 
finds  in  the  X-ray  plate  that  the  continuous  stomach  out- 
line becomes  broken  at  some  point,  the  break  being  due  to 
the  absence  of  bismuth  on  the  ulcer  surface.  All  this  knowl- 
edge came  from  the  work  of  Dr.  Walter  B.  Cannon,  who  first 
used  bismuth  X-ray  in  his  diagnostic  work  upon  cats. 

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THE  GASTRO-INTESTINAL  TRACT 

Gastritis,  or  inflammation  of  the  stomach,  used  to  be 
a  common  diagnosis.  To-day  we  can  be  pretty  sure 
when  we  hear  it  that  the  doctor  who  made  it  is  not 
up  to  date.  It  is  a  disease  which  I  have  not  seen  in 
the  last  two  years'  work  at  the  Massachusetts  General 
Hospital.  When  I  first  worked  there,  twenty  years 
ago,  we  made  the  diagnosis  of  gastritis  many  times 
a  day.  Gastritis  is  to-day  a  term  practically  confined 
to  alcoholics.  It  is  an  occasional  result  of  alcoholism. 
Not  all  alcoholics  get  gastritis,  but  some  of  them  do. 

Gastritis  is  recognized  by  the  presence  of  an  enor- 
mous mass  of  mucus  in  the  contents  issuing  out  of  the 
stomach  through  the  tube.  This  occurs  chiefly  in  alco- 
holics. It  is  a  rare  disease  and  not  important. 

At  this  point  I  wish  to  say  something  about  the  use 
of  the  stomach  tube.  Any  layman  may  have  to  advise, 
encourage,  support,  or  comfort  some  one  who  must 
have  the  tube  used  on  him.  The  stomach  tube  is  a 
rather  firm  red  rubber  tube  about  as  thick  as  the  finger. 
It  is  passed  straight  down  from  the  mouth  to  the 
stomach.  We  have  a  mark  upon  the  stomach  tube 
which  comes  opposite  the  patient's  front  teeth  when 
the  end  of  the  tube  has  reached  the  stomach.  In  people 
who  have  no  serious  disease  of  the  heart,  lungs,  or 
throat,  and  are  conscious,  it  is  practically  harmless  to 
pass  it,  and  in  every  great  hospital  it  is  passed  many 
times  a  day  with  good  result.  With  serious  heart  or 
lung  disease  the  amount  of  coughing  or  retching  pro- 
duced by  the  tube  is  a  strain  to  which  it  may  not  be 

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safe  to  put  the  patient.  In  unconscious  patients  the 
natural  reflex  closure  of  the  respiratory  tube  does  not 
always  take  place,  and  so  the  tube  itself  or  other  sub- 
stances may  be  pushed  into  the  lungs  and  so  may  start 
pneumonia.  Whenever  a  person  is  conscious  the  re- 
flexes take  care  of  that.  The  epiglottis  closes  over  the 
mouth  of  the  wind  pipe  and  keeps  all  harmful  sub- 
stances out. 

We  should  warn  patients  that  they  will  feel  acutely 
nauseated  for  the  period  of  the  tube's  passage,  but 
that,  much  worse  than  that,  they  will  feel  as  if  they 
could  not  breathe  —  and  the  crucial  piece  of  informa- 
tion is  that  they  can  and  must  breathe.  I  can  remember 
perfectly  going  through  the  same  sensation  when  I 
took  the  tube,  and  saying  to  myself,  as  I  have  so  often 
said  to  patients,  "Breathe ! "  You  have  to  shake  your- 
self, or  the  patient,  into  breathing.  Then  things  go 
easily.  We  extract  the  stomach  contents  by  suction 
or  we  wash  them  out  by  siphonage. 

In  feeding  people  who  resist  feeding  we  ordinarily 
pass  the  tube  through  the  nose,  down  the  pharynx,  to 
the  stomach.  This  is,  of  course,  uncomfortable.  But 
I  do  not  believe,  as  I  said  before,  that  there  is  ever  any 
danger  in  it.  People  often  wash  their  own  stomachs 
out,  or  used  to,  just  as  they  wash  any  other  part  of 
the  body.  Nowadays  the  stomach  wash  is  not  used 
much  for  treatment,  so  it  is  only  once  or  twice  that  the 
patient  has  to  swallow  the  tube.  It  is  for  these  occa- 
sions that  the  above  counsels  have  to  be  passed  along. 

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THE  GASTROINTESTINAL  TRACT 

There  is  not  an  organ  in  the  body  which  may  not 
cause  stomach  symptoms,  and  it  is  for  that  reason  that 
stomach  symptoms  are  so  enormously  common,  al- 
though stomach  disease  is  rare.  Out  of  any  hundred 
patients  who,  in  answer  to  the  doctor's  "What  troubles 
you?"  would  say,  "My  stomach  troubles  me/'  not  over 
ten  have  any  disease  in  the  stomach,  for  cancer  and 
ulcer  are  practically  the  only  stomach  diseases,  and 
neither  is  common. 

I  should  say  that  the  commonest  cause  of  stomach 
complaints  is  nervousness  —  psychoneurosis  of  all 
types,  emotional  dyspepsia.  I  do  not  suppose  there  is 
any  one  who  has  not  experienced  this.  You  are  eating 
your  dinner,  and  some  bad  news,  or  some  exciting  emo- 
tion comes  in,  and  your  digestion  is  interrupted.  In 
people  whose  emotions  are  constantly  on  the  stretch 
this  may  last  for  weeks,  months,  and  years.  It  gets 
linked  up  very  soon  with  one  of  those  perversions  of 
consciousness  that  I  like  to  call  a  "  dislocation  of  con- 
sciousness," whereby  our  minds  become  burdensomely 
aware  of  what  we  ought  to  be  unconscious  of.  If  our 
attention  is  called  to  the  stomach,  it  may  be  hard  to 
get  our  attention  back  into  its  place,  which  is  on  the 
ordinary  and  extraordinary  affairs  of  everyday  life 
outside  us. 

The  effect  of  a  dislocation  of  consciousness  is  to 
make  the  movements  of  the  stomach  hurt.  It  is  for 
this  reason  that  in  the  treatment  of  such  things  we  use 
such  apparently  far-fetched  methods  as  sea  voyages 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

and  change  of  work.  We  need  to  change  the  focus  of 
attention.  , 

More  than  that,  we  have  to  nourish  the  patient. 
The  patient  who  has  nervous  dyspepsia  will  say  that 
a  given  food  —  milk  or  potato  or  bread  and  butter  — 
hurts  him;  he  stops  it;  the  stomach  is  ill-nourished  and 
feels  worse.  He  stops  meat,  and  feels  worse.  He  gives 
up  milk.  In  this  way  one  article  of  food  after  another 
is  cut  off  until  he  is  really  pretty  near  starvation  in 
this  process.  Laymen  can  often  help  the  physician  in 
starting,  encouraging,  or  commanding  patients  to  eat 
when  they  do  not  want  to  eat,  when  it  seems  to  them 
that  they  cannot  eat.  For  it  is  only  by  eating  and  so 
getting  the  stomach  and  the  whole  body  better  nour- 
ished, despite  the  pain  of  eating,  that  we  can  begin  to 
overcome  this  train  of  symptoms.  It  is  a  vicious  circle. 
We  cannot  eat  (so  we  think),  so  we  do  not  eat.  Then 
we  (including  the  stomach)  get  ill-nourished.  Then 
we  lose  appetite  and  think  we  cannot  eat,  so  we  do  not 
eat,  etc.,  etc. 

Every  disease,  pretty  much,  has  that  type  of  a  vi- 
cious circle.  We  break  in  at  some  point  in  the  circle :  e.g. 
by  changing  the  point  of  view,  or  by  making  the  patient 
less  conscious  of  his  disease  and  so  more  willing  to  eat,  or 
by  forcing  him  to  eat.  There  is  nothing  that  needs  to 
be  said  more  often,  to  people  with  this  type  of  trouble, 
than  that  they  must  push  through  pain  into  freedom 
from  pain,  and  I  often  use  with  them  the  example  of 
what  happens  to  the  muscles  of  an  arm  after  a  fracture. 

104 


THE  GASTROINTESTINAL  TRACT 

When  an  arm  has  been  broken  it  is  put  in  a  splint;  while 
the  bone  knits  the  idle  muscles  waste  away  and  the 
ligaments  and  tendons  stiffen.  The  result  is  that  when 
the  person  is  cured  of  the  broken  bone  he  must  get 
over  the  results  of  the  treatment  of  the  broken  bone,  by 
forcing  himself  to  use  the  arm  in  spite  of  pain  —  push- 
ing through  pain'to  freedom.  It  is  wonderful  how  many 
types  of  human  trouble  this  applies  to. 

Dyspepsia  is  a  symptom  of  disease;  a  part,  never  the 
whole.  It  merely  means  that  one  has  trouble  with  his 
digestion,  the  cause  of  which  one  does  not  yet  know. 
Dyspepsia  may  be  due  to  disease  in  any  organ  of  the 
body,  starting  at  the  top. 

(i)  Begin  with  diseases  of  the  brain  as  causes  of  dys- 
pepsia. Nervous  dyspepsia  or  better,  emotional  dys- 
pepsia, is  one  of  the  commonest  of  these  types.  Emo- 
tional dyspepsia  is  ordinarily  an  interference  with  the 
completeness  of  the  process  of  digestion.  Emotion 
stops  it  in  the  middle,  or  prevents  it  from  being  car- 
ried on  as  it  should  be.  The  investigation  of  the  stom- 
ach in  such  cases  either  shows  nothing  or  shows  stagna- 
tion of  food,  but  no  disease.  Indeed,  investigation  of  the 
stomach,  in  the  vast  majority  of  cases  in  which  we  in- 
vestigate with  the  tube  and  the  X-ray,  shows  nothing. 
That  is  part  of  our  evidence  that  the  trouble  is  in 
some  other  organ.  The  dyspepsia  itself  may  not  differ 
at  all  so  far  as  the  particular  complaints  are  con- 
cerned, in  these  functional  cases  of  troubles  outside 
the  stomach,  from  the  stomach  diseases  themselves. 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

The  feelings  within  the  stomach  itself  are  not  charac- 
teristic. One  relies  on  the  results  of  general  physical 
examination,  tube  examination,  and  X-ray  examina- 
tion. Emotional  dyspepsias  are  furthermore  generally 
to  be  recognized  by  the  fact  that  definite  emotional 
troubles  aggravate  them.  The  removal  of  these 
troubles  makes  the  patient  better. 

There  is  almost  always  association  with  constipa- 
tion. Emotional  dyspepsia  with  constipation  may  lead 
to  great  weakness  and  emaciation,  through  a  person's 
cutting  off  one  article  of  food  after  another  because  he 
associates  it  with  stomach  distress,  so  that  in  the  end 
a  purely  nervous  or  emotional  dyspepsia  may  be  a 
serious,  thing  and  may  cause  death,  through  the  re- 
fusal of  food  and  the  malnutrition  that  results.  This 
extreme  type  is  called  anorexia  nervosa. 

The  layman's  part  in  the  care  of  any  one,  said  by 
his  physician  to  have  nervous  dyspepsia,  is  to  help  the 
physician  in  encouraging  that  person  to  disregard  it, 
to  go  ahead  in  spite  of  it,  to  eat  even  when  it  hurts,  to 
get  his  mind  if  possible  occupied  with  other  things. 
There  are  some  people  who  cannot  digest  if  they 
eat  alone.  Their  minds  get  on  themselves,  and  make 
trouble,  as  minds  always  do  make  trouble  when  they 
interfere  with  that  which  is  meant  to  go  on  uncon- 
sciously. 

(2)  Besides  "nervousness,"  any  organic  disease  of 
the  brain  may  cause  dyspepsia  and  vomiting —  for  in- 
stance, brain  tumor  and  meningitis.  Patients  also 

106 


THE  GASTRO-INTESTINAL  TRACT 

vomit  in  "softening  of  the  brain, "  that  is,  syphilitic 
disease  of  the  brain.  They  vomit  in  cerebral  arterio- 
sclerosis, and  there  are  often  other  stomach  symptoms 
too  with  that  last  disease. 

(3)  The  lungs  lead  to  stomach  trouble,  most  often 
when  they  are  tuberculous;  indeed,  the  stomach 
troubles  of  tuberculosis  may  be  the  only  thing  that  the 
patient  complains  of.  Every  year  we  have  cases  sent 
into  our  hospital  wards  for  supposed  stomach  disease, 
and  when  they  are  studied  it  is  shown  that  the  whole 
trouble  is  in  the  lungs,  while  the  stomach  is  perfectly 
sound.  In  those  cases  we  direct  our  whole  attention  to 
the  lungs,  and  the  stomach  straightens  itself  out.  I  re- 
member well  one  of  the  first  visits  that  I  paid  to  the 
Rutland  Sanatorium,  at  a  time  when  I  had  not  learned 
much  about  the  treatment  which  is  now  carried  on  in  all 
sanatoria.  Dr.  Vincent  Bowditch  was  then  in  charge. 
I  remember  questioning  him  somewhat  in  this  way:  — 

"What  do  you  do  for  night  sweats?  Do  you  use 
agaricin,  atropin,  cold  sage  tea,  or  what?'* 

"We  do  not  use  any  drugs,"  he  said.  "We  put  the 
patients  outdoors  and  they  soon  stop  sweating  as  fever 
abates." 

"Well,  do  you  believe  in  the  antipyretic  drugs  to 
check  fever?" 

"No,"  he  said,  "we  put  the  patients  to  bed,  and  put 
them  outdoors,  and  the  fever  stops." 

"But,"  said  I,  "you  surely  must  use  some  expecto- 
rants for  cough?" 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

r"  "No,  really,"  Dr.  Bowditch  replied;  "after  we  put 
them  out  of  doors  for  a  little  while  they  cease  to  cough." 

"Still,  you  must  have  something  to  give  them  an  ap- 
petite.  Do  you  use  nux,  ipecac,  capsicum,  gentian?" 

The  same  answer. 

;  And  so  with  the  stomach  troubles.  They  all  vanish 
when  the  patient  begins  to  get  on  the  right  track,  and 
they  won't  any  of  them  vanish  until  he  does.  One  can 
hardly  believe  this  until  he  has  seen  it.  We  absolutely 
disregard  these  stomach  symptoms  and  treat  the  pa- 
tient wholly  for  his  lungs ;  then  the  stomach  straightens 
itself  out. 

(4)  Diseases  of  the  heart,  when  the  circulation  through 
the  stomach  as  well  as  through  the  other  organs  is  de- 
layed by  stagnation  of  the  blood,  produce  dyspepsia, 
vomiting,  and  this  may  be  almost  the  only  thing  the 
patients  complain  of.   They  may  have  only  a  mild 
type  of  dyspepsia,  but  practically  all  of  them  have  some 
trouble  with  their  stomachs.  Again,  what  we  do  is  to 
treat  the  heart,  and  when  we  can  get  the  heart  to  pump 
properly,  when  we  can  get  the  congestion  out  of  the 
vessels  in  the  stomach,  it  does  its  proper  work. 

(5)  Diseases  of  the  liver,  and  especially  alcoholic  cir- 
rhosis, produce  congestion  of  the  stomach  because  the 
blood  that  passes  from  the  stomach  goes  to  the  liver, 
is  blocked  there  by  the  diseased  tissue,  and  so  backs 
up  in  the  stomach  and  engorges  it.    We  often  have 
hemorrhage  from  the  stomach  in  alcoholic  cirrhosis,  so 
that  a  great  many  of  these  cirrhotic  patients  are  falsely 

108 


THE  GASTROINTESTINAL  TRACT 

supposed  to  have  a  bleeding  ulcer.  When  a  patient 
who  has  been  previously  well  suddenly  vomits  blood  in 
large  amount,  the  most  probable  solution  is  that  he  has 
alcoholic  cirrhosis  of  the  liver,  with  backing  up  of  blood 
in  the  stomach  and  finally  hemorrhage. 

(6)  Diseases  of  the  intestine,  especially  obstruction, 
so  that  the  intestinal  contents  do  not  pass  on,  disturb 
the  stomach  and  lead  to  all  the  familiar  symptoms  of 
dyspepsia,  but  especially  to  persistent  vomiting. 

(7)  Many  chronic  diseases  of  the  kidneys  produce 
dyspepsia,  and  are  often  overlooked.  That  is  one  of  the 
things  that  I  think  even  social  workers  ought  to  be  on 
the  lookout  for.    Pretty  nearly  every  week  we  see  in 
the  paper  that  the  Honorable  Mr.  So-and-So,  while 
making  an  after-dinner  speech,  was  seized  with  "  acute 
stomach  trouble,"  was  taken  to  his  hotel,  and  soon 
died.  That  is  never  true.   Nobody  was  ever  killed  by 
an  attack  of  acute  stomach  trouble.   There  was  long 
standing  organic  disease  in  some  other  organ  of  his 
body.    The  sick  organ  is  probably  his  heart,  the  next 
chance  is  his  kidneys,  and  the  third  chance  his  brain. 
Excitement  or  fatigue  upset  the  balance  or  drawn 
battle  between  nature  and  the  disease.  Then  came  the 
stomach  symptoms.  Nobody  is  ever  in  danger  from 
acute  stomach  troubles,  unless  he  has  swallowed  cor- 
rosive sublimate  or  violent  irritant  poison. 

(8)  Industrial  diseases  produce  stomach   trouble. 
The  commonest  and  only  well-known  industrial  dis- 
ease, lead  poisoning,  is  the  most  likely  of  all  to  pro- 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

duce  stomach  symptoms,  but  commoner  than  any  defi- 
nite industrial  disease  is  industrial  fatigue  as  a  cause 
of  dyspepsia ' —  hard  work,  overwork,  and  worry.  The 
exhaustion  from  excessive  labor,  or,  more  often,  from 
the  mental  or  physical  conditions  under  which  labor  is 
done,  often  makes  the  stomach  rebel. 

(9)  Many  diseases  of  the  blood,  including  all  the 
anemias,  show  themselves  chiefly  as  a  rule  by  stomach 
trouble  and  general  weakness*. 

I  think  I  have  given  a  list  sufficient  to  indicate  that 
the  stomach  manifests  troubles  in  all  the  other  organs. 
Dyspepsia,  therefore,  is  not  characteristic  of  any  dis- 
ease in  the  stomach  itself. 


CHAPTER  V 

DIET  —  CONSTIPATION 

Diet  , 

ALMOST  nothing  is  known  about  diet.  There  are  nu- 
merous weighty  books  on  the  subject  which  are  useful 
for  pressing  leaves,  but  not  for  much  that  they  contain. 
All  that  is  really  known  about  diet  can  be  contained  in 
a  very  small  book,  and  one  of  the  most  encouraging 
signs  of  the  times  is  that  books  on  diet  are  getting 
smaller.  The  man  who  probably  knows  as  much  about 
it  as  anybody  in  the  United  States  is  Dr.  Graham  Lusk. 
He  has  published  a  book  of  fifty-one  pages,1  which  con- 
tains almost  all  the  known  wisdom  on  the  subject  —  a 
most  refreshing  contrast  to  the  old  wives'  tales  that 
are  so  numerous  and  so  dull  in  long  books  on  this  sub- 
ject. Everything  in  it  is  true,  and  there  is  nothing  in  it 
that  is  not  true.  I  do  not  know  of  any  other  book  about 
diet  of  which  that  can  be  said. 

Diet  is  a  very  individual  matter.  We  do  not  quite 
realize  often  how  much  meaning  there  is  in  the  phrase, 
"  It  is  a  matter  of  taste  "  — taste  in  the  literal  sense.  It 
is  owing  to  that,  I  think,  that  so  many  false  ideas  have 
got  abroad.  I  had  an  uncle  who  was  a  physician  and 
who  had  very  strong  convictions  on  the  subject  of  jelly. 
The  result  was  that  if  anybody  who  was  sick  had  been 

1  Graham  Lusk,  M.D.:  The  Fundamental  Basis  of  Nutrition. 
Ill 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

taking  any  gelatine  within  any  reasonable  time,  that 
was  apt  to  be  blamed  as  the  cause  of  the  trouble.  There 
was  another  very  well-known  Boston  physician  some 
years  ago  who  had  strong  beliefs  about  oranges.  If  you 
came  to  him  about  your  headache,  or  a  pain  in  your 
knee,  he  would  say :  - 

"Have  you  been  eating  oranges  lately?'* 
If  the  patient  denied  this,  he  would  say,  "When  did 
you  eat  any  oranges?" 
"Last  summer." 

"Ah!  That 'sit!  They  are  still  poisoning  you." 
It  is  very  hard  for  physicians  not  to  inflict  their  pri- 
vate preferences  on  their  patients,  and  I  think  this 
accounts  for  the  large  size  of  the  older  books  on  diet. 

i?  We  divide  foods  into  three  classes :  proteids,  carbohy- 
drates, and  fats.  The  simple  way  to  remember  them  is 
to  memorize  the  proteids  and  the  fats,  which  are  very 
few,  and  then  to  assume  that  everything  else  is  carbo- 
hydrate. 

Proteids  are  meat,  fish,  milk,  and  eggs.  There  is  some 
proteid  in  cheese  and  in  vegetables,  but  that  does  not 
need  to  be  considered  in  a  rough  sketch  like  this.1 

Fats  include  butter,  cream,  some  cheeses,  the  fat  in 
meat,  the  oils,  such  as  olive  oil  and  cotton-seed  oil  (which 
is  often  used,  although  we  do  not  always  recognize  it  as 
such).  Of  course  bacon  is  the  fat  of  meat,  although  we 

1  Rice  contains  2.8  per  cent  of  proteid;  beans,  9.4  per  cent;  Dutch 
cheese,  37.1  per  cent;  cream  cheese,  25.9  per  cent. 

112 


DIET  — CONSTIPATION 

do  not  always  think  of  it  just  that  way,  and  the  yolk  of 
egg  is  practically  pure  fat.  There  is  very  little  fat  in 
Dutch  cheese.  It  is  the  soft  ones  that  have  fat. 

Leaving  out  the  few  foods  which  I  have  listed,  almost 
everything  else  is  carbohydrate,  and  that  reduces  the 
necessities  of  memory  to  a  pretty  small  number.  . 

Now  it  seems  to  be  true  that  people,  who  have  been 
brought  up  as  we  have,  need  a  "balanced  dietary"; 
that  is,  a  certain  allowance  of  each  of  the  three  kinds 
of  food.  Many  Esquimaux  are  healthy,  and  they  never 
have  a  balanced  dietary.  Many  Hindus  are  healthy, 
and  they  never  have  a  balanced  dietary.  The  South 
Italians  are  healthy,  though  they  rarely  eat  meat.  But 
they  are  used  to  it,  and  we  .are  not.  We  have  been 
pampered  for  many  generations.  The  Esquimaux 
never  have  any  carbohydrates,  and  the  Hindus  have 
scarcely  anything  else,  but  they  have  got  used  to  it.  I 
think  the  best  one  can  say  for  us  is,  that  after  we  have 
been  used  to  it  for  so  many  generations  as  we  have,  it 
does  not  pay  to  throw  out  any  one  of  the  three  main 
classes  of  food.  Therefore,  in  thinking  of  our  diet  or  of 
that  of  our  friends,  we  should  try  to  arrange  that  the 
three  classes  of  foods  are  represented,  and,  in  a  general 
way,  that  no  one  of  them  is  tremendously  in  excess  of 
the  average  eaten  by  those  who  can  get  what  they 
want.  I  believe  that  adults  who  have  been  pampered 
as  we  have,  had  better  have  proteid  in  some  form  at 
least  once  a  day,  if  not  more.  If  they  cannot  get  meat, 
they  had  better  have  eggs  or  milk. 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

The  more  we  study  the  diet  of  different  people,  the 
more  cautious  we  shall  be  in  laying  down  the  law  about 
what  people  must  eat.  The  Italian  laborer  can  do  more 
work  in  a  day  than  most  Americans  can  do  in  two, 
and  yet  he,  as  a  rule,  has  little  but  carbohydrates  in  his 
diet,  little  fat,  and  almost  no  proteids;  but  then  he  is 
used  to  it. 

Very  little  is  known  about  the  so-called  "  indigestible 
foods. "  Indigestible  food  represents  the  idiosyncrasies 
of  the  individual,  not  wholly  but  mostly.  What  is  in- 
digestible for  one  person  is  often  easily  digested  by 
another.  » 

Cherries  and  milk  are  supposed  to  be  a  fatal  mixture, 
but  we  find  that  even  the  timid  will  take  the  cherries 
and  a  little  later  on  will  have  tea  with  cream.  The 
same  superstition  exists  about  shellfish,  oysters,  or 
soft  crabs  with  ice-cream,  or  oysters  and  milk.  I  think 
there  I  have  some  idea  how  the  notion  started.  I 
fancy  it  arose  in  relation  to  taste.  If  you  eat  oysters 
and  then  drink  milk,  the  milk  tastes  queer.  I  suppose 
that  is  the  way  that  the  idea  of  their  incompatibility 
arose.  The  person  who  is  said  to  be  ill  as  the  result  of 
eating  one  of  these  mixtures  is  really  ill  from  some- 
thing el§e.  The  trouble  is  usually  with  his  heart  or  his 
kidneys  or  his  brain,  or  his  appendix.  A  person  has  al- 
most always  eaten  something  before  he  is  taken  ill  in 
the  night,  and  then  that  something  is  blamed.  I  am 
speaking  now  of  mixtures  of  substances  supposed  to  be 
separately  harmless.  I  am  quite  sure  there  is  no  such 

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,  DIET— CONSTIPATION 

thing  as  an  indigestible  mixture  of  two  digestible  things. 

The  chefs  always  have  strong  ideas  about  this.  They 
warn  us  against  the  mixture  of  milk  and  acid  fruit,  for 
instance,  and  tell  us  that  the  acid  of  the  fruit  may  curdle 
the  milk,  which  is  true,  but  as  soon  as  the  milk  reaches 
the  stomach  it  curdles  anyway.  There  is,  however, 
something  to  be  said  here  in  relation  to  different  kinds 
of  curds.  If  one  takes  a  large  quantity  of  milk  as  fast 
as  he  can  drink  it  down,  it  will  sometimes  form  a  partic- 
ularly tough  curd  in  the  stomach  which  is  quite  a  job 
for  the  stomach  to  break  up.  It  forms  a  very  different 
curd  if  we  sip  the  same  amount  of  milk  with  a  bite  of 
cracker  between  the  sips.  It  then  forms  a  loose  curd  on 
which  the  stomach  does  not  have  to  do  any  hard  me- 
chanical work. 

Any  one  can  take  milk.  If  a  person  tells  me,  "  I  can- 
not take  milk,"  I  always  say,  "You  can  if  you  will  take 
it  in  a  certain  way."  It  is  a  question  usually  of  flavor- 
ing it  aright  or  of  taking  it  like  soup,  with  a  spoon,  with 
a  bite  of  some  carbohydrate  substance,  cracker  or 
bread,  between  the  sips.  I  do  not  think  everybody 
must  take  milk,  but  I  think  everybody  can. 

Some  foods  take  a  long  time  to  digest  because  they 
contain  so  much  fat  or  so  much  waste,  what  is  called 
4 'cellulose,"  the  stalky  parts  of  vegetables.  Foods 
which  contain  a  great  deal  of  cellulose  are  apt  to  be 
slow  in  leaving  the  stomach.  Again,  fats  are  slow  in 
leaving  the  stomach,  and  that  leads  many  people  to 
think  that  they  are  indigestible.  If  we  have  taken  a 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

great  deal  of  fat,  we  may  be  made  aware  of  its  presence 
in  the  stomach  for  some  time  after  we  have  taken  it,  but 
that  means  merely  that  we  have  not  yet  digested  it. 
" Rich  foods"  are  full  of  fat,  and  hence  are  slow  of  di- 
gestion but  very  nourishing.  If  an  empty  stomach  is 
needed  in  the  prosecution  of  business  for  an  actor,  a 
speaker,  or  a  singer,  it  is  better  to  put  in,  not  fat,  but 
something  that  quickly  leaves  the  stomach,  and  that  is 
carbohydrates  and  water.  Carbohydrates  and  water 
leave  the  stomach  quickest.  The  actor  who  is  going  to 
perform  in  the  evening  has  tea  and  toast  at  about  five 
o'clock ;  then  his  stomach  is  empty  at  the  time  he  goes 
to  work,  and  yet  he  has  had  some  food  and  his  tissues 
are  not  then  calling  for  more.  After  he  is  all  througji 
his  work  he  has  a  full  meal. 

Fats  leave  the  stomach  slowest,  carbohydrates  leave 
the  stomach  quickest,  proteids  are  intermediate.  Al- 
most everything  known  on  this  subject  is  the  work  of 
Dr.  Walter  B.  Cannon,  of  the  Harvard  Medical  School, 
who  watched  with  the  X-ray  the  progress  of  foods 
mixed  with  bismuth;  but  one  can  confirm  it  very 
easily  by  one's  own  experience.  A  good  many  foods  are 
cut  out  of  the  diet  of  invalids  because  they  are  said  to 
be  "indigestible,"  but  in  reality  only  because  they  re- 
quire a  good  deal  of  chewing.  A  person  fighting  ty- 
phoid fever  should  not  have  any  extra  muscular  work 
put  on  him,  such  as  walking,  talking,  chewing.  To-day 
this  is  about  the  only  limitation  we  put  on  the  foods 
of  febrile  patients.  It  used  to  be  supposed  that  fever 

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DIET  —  CONSTIPATION 

patients  could  not  take  meat ;  they  should  not  take  it 
in  the  ordinary  form  because  it  is  too  much  work  to 
chew  it,  but  if  we  chop  it  up  fine  they  will  generally 
take  care  of  it  perfectly  well.  All  our  typhoid  patients 
at  the  Massachusetts  General  Hospital  are  now  al- 
lowed meat  during  the  worst  periods  of  the  disease. 

We  do  not  need  to  weigh  out  our  diet.  We  need  to  eat 
enough  so  as  to  feel  well  and  to  weigh  what  we  ought  to 
weigh.  There  is  no  other  satisfactory  guide.  A  person 
can  find  out  quite  easily  what  at  his  height  should  be 
his  weigfit.  If  he  weighs  more  than  this,  he  ought  to 
eat  less ;  if  he  weighs  less,  he  ought  to  eat  more.  That, 
of  course,  has  to  be  a  general  statement.  I  think  the 
Lord  has  definite  ideas  about  some  people  who  ought 
to  be  thin,  and  others  who  ought  to  be  fat.  Certainly 
there  are  people  who  can  eat  almost  double  the  average 
diet  and  never  gain  an  ounce,  and  there  are  other 
people  who  will  get  fat  on  a  diet  that  would  not  keep  a 
bird  alive.  But  these  extremes  are  merely  exceptions  to 
the  rule,  that  one  ought  to  weigh  what  a  person  of  his 
height  should  weigh,  and  govern  his  diet  accordingly. 

The  American  people  as  a  whole  bolt  their  food 
without  chewing  it,  and  get  along  perfectly  well  never- 
theless. They  undoubtedly  put  an  unnecessary  bur- 
den on  their  stomachs,  which  is  a  stupid  thing  to  do, 
though  it  usually  has  no  consequences  that  we  can  de- 
tect. Now  and  then  we  get  hold  of  some  unfortunate 
individual  who  has  dyspepsia  and  we  find  out  that  he 
bolts  his  food.  We  do  not  question  his  hundred  and  one 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

neighbors  who  also  bolt  their  food  without  chewing  it, 
and  get  along  perfectly  well.  We  must  not  exaggerate 
the  value  of  chewing,  but  nevertheless  it  is  a  sensible 
thing  to  do.  The  teeth  are  meant  to  chew,  and  if  we 
bolt  our  food  the  stomach  may  have  a  hard  time  doing 
the  work  of  the  teeth.  The  stomach  is  a  soft,  flabby 
organ,  and  it  seems  irrational  not  to  give  our  teeth 
something  to  do.  But  Fletcherism  is  a  fad  already 
defunct. 

For  a  long  time  there  has  been  a  superstition  that  we 
should  not  drink  water  with  our  meals,  either  on  the 
ground  that  it  is  bad  for  the  digestion,  or  because  it  is 
supposed  to  make  us  fat.  If  we  do  not  drink  any  water 
with  our  meals,  we  cannot  eat  so  much,  and  therefore 
we  lose  flesh.  That  is  the  origin  of  the  idea,  I  suppose. 
But  if  we  measure  out  a  given  amount  of  foodrand  eat 
it  with  water  at  meals,  and  then  later  without  water 
at  meals,  we  find  that  we  weigh  just  as  much.  The 
truth  is  that  the  vast  majority  are  better  for  drinking 
with  their  meals.  If  there  are  individual  idiosyncra- 
sies it  does  not  change  the  rule.  The  fallacy  may  have 
arisen  from  the  fact  that  if  we  drink  enough  iced  water 
with  our  meals,  —  a  quart  or  two,  —  we  may  be  able 
to  cool  down  the  stomach  so  that  digestion  does  not 
go  on  so  well. 

There  is  another  fallacy,  that  very  cold  water  is  bad 
for  the  digestion.  There  is  nothing  in  it.  I  remember 
the  grave  and  fatherly  reproof  of  the  waiter  in  England 
when  I  asked  for  iced  water,  "Oh,  no,  sir,  very  bad  for 

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DIET  — CONSTIPATION 

the  digestion."  But  I  had  the  iced  water  all  the  same. 
Extreme  heat  or  extreme  cold  both  stimulate  the  cir- 
culation and  digestion.  It  is  the  lukewarm  things 
which  we  are  advised  to  take  which  really  retard  diges- 
tion. Any  digestion  which  is  delicate  may  need  stimu- 
lation, and  the  simplest  stimulation  is  from  heat  or 
cold.  I  do  not  mean  to  say  that  if  one  does  not  like 
iced  water  he  must  drink  it,  but  there  is  no  reason  why 
one  should  not  take  it. 

The  taste  of  food,  as  Professor  Cannon,  and  before 
him  Professor  Pawlow,  of  Russia,  has  demonstrated, 
is  not  merely  a  " matter  of  taste,"  it  is  a  matter  of 
hydrochloric  acid  in  the  stomach.  Eating  a  food  that 
we  like  is  followed  by  the  secretion  of  gastric  juice  in 
the  stomach.  That  is  true  whether  one  is  a  human  be- 
ing or  a  dog.  Professor  Pawlow  established  an  opening 
in  the  stomach  of  a  dog  and  was  able  to  observe  that 
when  a  dog  chews,  or  even  sees,  across  the  room,  a 
food  which  he  likes,  his  stomach  immediately  begins  to 
secrete  gastric  juice.  The  idea  that  if  we  really  like  a 
thing  it  must  be  bad  for  us,  is  just  the  opposite  of  true. 
Liking  is  the  proof  of  HCL  secretion  which  is  important 
in  digestion,  though  it  is  not  the  only  thing  needed. 

I  like  to  point  out  from  time  to  time  some  of  the 
things  that  amaze  me  most  in  the  arrangements  of  the 
human  body.  Some  of  these  in  the  stomach  are  as  fol- 
lows :  When  we  eat  carbohydrates  the  stomach  secretes 
an  appropriate  juice,  a  gastric  juice  of  different  com- 
position from  that  which  it  secretes  if  it  finds  proteids 

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A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

coming  down.  This  is  a  response,  and  a  most  intelli- 
gent response,  to  the  particular  demand  that  is  made 
on  the  stomach.  It  is  one  of  the  numerous  examples 
of  choice  or  intelligent  guidance  carried  on  by  parts  of 
the  body  which  are  ordinarily  thought  of  as  uncon- 
scious and  having  no  soul  or  choice  of  their  own.  To 
me  it  is  a  proof  that  the  soul  —  i.e.,  choice  —  is  pres- 
ent in  every  part  of  the  body. 

Question  and  Answer 

Q.  You  spoke  of  the  selective  action  of  the  stomach ;  does 
that  mean  that  there  is  a  chemical  change  in  the  juices  ac- 
cording to  the  food  taken? 

A.  Yes;  just  that.  It  seems  to  me  a  most  extraordinary 
fact.  So  far  as  I  know,  it  has  nothing  to  do  with  the  part  that 
the  stomach  plays  in  the  digestion  of  food.  That  is  quite  a 
different  thing.  The  stomach  does  very  little  in  the  chemical 
digestion  of  food ;  its  job  is  chiefly  mechanical.  It  does  a  little 
on  the  proteids,  very  little  on  the  carbohydrates  and  fats.  It 
is  mostly  useful  to  store  food,  as  a  squirrel  stores  it  in  his 
cheek;  it  then  pays  it  out  to  the  intestine  as  the  work  of  the 
intestine  is  done.  The  saliva  does  a  little  to  change  carbo- 
hydrates into  the  more  digestible  form,  but  not  much.  De- 
spite Mr.  Horace  Fletcher,  prolonged  chewing  has  not  come 
into  any  vogue  and  does  not  deserve  to.  The  work  that  the 
stomach  does  the  pancreatic  juice  does  anyway. 

I  must  not  leave  the  subject  of  diet  without  speak- 
ing of  the  burning  question  of  candy.  When  I  was  a 
child  every  one  knew  that  candy  was  a  sin,  and  of 
course  children  were  allowed  as  little  as  possible.  To- 
day we  know  that  it  is  one  of  the  most  valuable  foods, 
and  that  the  chief  danger  is  that  one  overdoes  it. 

120 


DIET  —  CONSTIPATION 

Candy  or  any  other  sweet  is  apt  to  take  away  an  appe- 
tite for  other  foods.  That  is  the  harm  that  it  does. 
After  meals,  after  you  have  had  other  foods,  there  is 
no  harm  in  it.  But  candy  is  not  the  only  food  in  the 
world,  and  some  people  tend  to  treat  it  as  if  it  were,  just 
as  some  gentlemen  tend  to  treat  whiskey  as  if  it  were 
the  only  food  in  the  world.  Hence  trouble  arises. 

I  do  not  advise  the  layman,  either  for  himself  or  for 
those  whom  he  tries  to  help,  to  calculate  out  the  calory 
value  of  foods,  the  food  value  of  weighed  portions,  or 
to  work  out  the  mathematics  of  diet.  There  is  no  need 
of  it.  We  can  tell  by  rough  estimates  and  measures 
whether  a  person  is  eating  enough.  It  is  important,  of 
course,  to  know  something  of  the  kinds  of  food,  for  the 
reasons  I  have  given.  The  precise  amount  will  take 
care  of  itself  in  the  vast  majority  of  cases.  When  Dr. 
D.  L.  Edsall  was  appointed  physician  to  the  Mass- 
achusetts General  Hospital,  I  asked  him  whether  he 
thought  diets  ought  to  be  weighed  out  by  calories  in  the 
wards,  because  he  probably  knows  more  about  diet  and 
nutrition  than  any  practising  physician  in  this  country. 
To  my  great  satisfaction  Dr.  Edsall  answered  that  he 
did  not  think  there  was  any  sense  in  calculating  calory 
values  in  routine  ward  diets,  because  we  could  judge 
of  patients'  diet  and  nutrition  in  other  and  simpler 
ways. 

Still,  as  it  is  an  advantage  to  understand  the  words 
that  medical  people  often  use,  I  will  go  on  to  explain 
that  the  calory  value  of  food  is  the  common  denominator 

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to  which  we  can  reduce  foods  when  we  want  to  com- 
pare their  power  to  nourish  and  warm  the  body.  A 
food's  calory  value  is  the  amount  of  heat  which  the  food 
would  produce  if  burned.  If  we  burn  an  ounce  of  sugar, 
it  will  cause  a  certain  amount  of  heat;  if  we  burn  an 
ounce  of  olive  oil,  it  will  produce  another  and  much 
larger  amount  of  heat.  The  nutritive  power  of  food  is 
roughly  parallel  to  the  amount  of  heat  it  produces,  and 
it  is  on  that  basis  that  the  calory  values  of  food  are 
calculated.  ' '  Calory ' '  and  ' 'caloric ' '  are  from  the  same 
word  which  means  heat.  Calory  value  is  heat  value. 
We  say  that  the  average  individual  needs  about 
twenty-five  hundred  calories  of  food  a  day ;  that  is,  the 
amount  of  heat  which  the  food  he  eats  will  produce. 

How  do  we  obtain  that  knowledge?  Simply  by  find- 
ing out  how  much  people  do  eat  and  taking  that  as  the 
right  (or  average)  standard.  That  is,  the  basis  of  nu- 
trition at  the  present  time,  the  standard  of  calory  value 
worked  out  by  Voit,  of  Germany,  is  nothing  but  an 
enormous  compilation  of  what  German  laborers,  stu- 
dents, etc.,  actually  do  eat.  The  presumption  at  the 
base  of  our  standard  is  that  people  eat  what  they  ought 
to  eat  in  amount  and  kind,  which  I  think  is  a  pretty 
true  assumption  for  most  people. 

Do  most  of  us  eat  too  much  meat?  Rarely  in  youth. 
We  seem  to  have  evidence  that  growing  children  need 
abundant  meat.  I  do  not  think  that  the  evidence 
is  very  good,  but  it  seems  to  me  on  the  whole  better 
than  nothing.  But  we  also  seem  to  have  evidence 

122 


DIET  —  CONSTIPATION 

that  people  who  are  past  middle  life  can  easily  overdo 
on  meat,  and  had  better  eat  very  little;  by  very  little, 
I  mean  one  help  once  a  day. 

If  we  take  a  tablespoonful  of  olive  oil  we  are  getting 
more  food  than  if  we  took  a  large  potato,  for  instance, 
because  oil  is  a  food  which  produces  so  much  heat.  All 
the  fats  are  tremendously  concentrated  foods.  Among 
the  carbohydrates  food  values  are  inversely  propor- 
tional to  the  amount  of  cellulose ;  that  is,  to  the  amount 
of  stalk.  Lettuce,  for  instance,  is  a  food  practically 
without  value  —  nice  and  pleasant  to  look  at,  and  val- 
uable so  far  as  it  has  dressing  (made  with  oil).  But  the 
dressing  is  the  only  thing  that  has  any  food  value.  Rice 
and  beans  are  the  carbohydrates  that  contain  the  larg- 
est amount  of  food  in  proportion  to  cost.  Five  cents' 
worth  of  either  of  those  contains  more  nutrition  than 
anything  else  that  can  be  had  for  the  same  price. 

There  is  vastly  more  nutrition  in  a  cup  of  pea-soup 
than  in  a  cup  of  beef -tea.  There  is  no  nutrition  in  beef- 
tea  as  ordinarily  made.  It  has  value  as  heat,  as  savory, 
and  as  stimulant,  in  the  sense  of  stimulating  the  flow 
of  gastric  juice,  and  through  its  heat  it  brings  blood  to 
the  surface  of  the  stomach.  But  it  is  almost  impossible 
tp  make  it  so  that  it  has  any  nourishment.  Beef- juice 
squeezed  out  of  the  meat  has  much  nourishment  in  it. 
That  is  very  different  from  beef-tea.  Pea-soup  con- 
tains a  large  amount  of  nutrition  because  peas  are 
among  the  most  nutritious  things  that  we  eat.  The 
clear  soups  are  useful  chiefly  as  preparing  the  stomach 

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for  real  foods  which  are  to  come  later.  The  stomach 
likes  to  get  about  that  amount  of  warming. 

What  I  have  just  said  about  the  value  of  clear  soups, 
chiefly  as  preparing  the  way  for  real  food  to  come  later, 
reminds  me  of  what  Woods  Hutchinson  says  about 
the  popular  modern  breakfast  foods:  that  they  are  all 
right  provided  you  eat  your  breakfast  afterwards. 
That  is  pretty  strong,  because  almost  nobody  eats 
them  without  cream  and  sugar,  which  are  highly  nour- 
ishing. But  the  cream  and  sugar  make  up  the  chief 
value  in  shredded  wheat,  maple  flakes,  etc.  The 
"trimmings"  are  more  valuable  than  the  food. 

Oatmeal  is  a  very  valuable  food  in  itself,  besides 
the  sugar  and  cream  that  we  ordinarily  add.  Woods 
Hutchinson  was  referring  to  the  more  modern  break- 
fast foods,  the  various  things  that  look  nice  and  feel 
pleasant  in  the  mouth,  but  which  have  not  much  nu- 
trition. Oatmeal,  rice,  hominy,  cracked  wheat,  rye, 
corn  meal  —  all  those  are  very  nutritious. 

The  value  of  malted  milk  depends  a  good  deal  on 
how  much  milk  we  add  to  it.  Most  of  the  directions 
given  for  the  use  of  malted  milk  say,  "Add  milk," 
"Add  cream."  Of  itself  it  is  mostly  carbohydrate,  and 
of  rather  small  food  value,  but  all  right  so  far  as  it  goes. 

Professor  Graham  Lusk,  whom  I  have  already  re- 
ferred to,  says  that  the  pure-food  laws  of  the  United 
States  ought  to  be  so  amended  that  on  every  package 
which  is  sold  the  food  value  is  in  some  way  indicated. 
The  question  of  the  purity  of  foods  is  comparatively 

124 


DIET  —  CONSTIPATION 

unimportant,  but  the  food  value  of  foods  in  proportion 
to  cost  is  important.  Professor  Lusk  says  that  a  work- 
ing man  who  buys  a  can  of  beans  ought  to  know  that 
he  is  getting  many  times  the  food  for  the  same  money 
as  when  he  buys  a  can  of  tomatoes.  Tomatoes  are 
ninety-four  per  cent  water;  there  is  hardly  any  nutri- 
tion in  them.1 

If  foods  were  labelled  in  this  way  it  would  be  far 
more  important  than  having  them  receive  or  not  re- 
ceive the  seal  of  the  United  States  in  relation  to  their 
purity.  Most  of  the  adulterants  which  are  mixed  with 
foods  are  harmless.  The  coloring  matters  one  can 
object  to  because  they  are  a  fake,  but  not  because  they 
are  poisonous.  The  green  which  makes  canned  peas 
green  is  artificial,  but  it  is  not  paris  green.  There  are 
dreadful  warnings,  issued  mostly  by  rival  manufac- 
turers, that  such  and  such  a  honey  or  preserve  is  made 
of  glucose,  just  as  if  glucose  were  not  one  of  the  most 
important  foods  —  namely,  grape  sugar.  The  joke 
about  the  harmless  alum  in  baking  powders  is  an  ex- 
ample of  how  capital  is  made  in  this  way.  The  makers 
whose  powder  does  not  contain  alum  (quite  harmless 
anyway)  m^ke  a  fearful  fuss  about  the  fact  that  it  does 
not,  and  mosV  of  the  time  that  this  noise  is  being  made, 
the  howlers  a-e  actually  putting  alum  into  their  own 
powder.  The  amount  of  copper  sulphate  put  into  foods 
does,  so  far  as  we  know,  no  harm.  It  is  the  same  with 

1  On  this  wh<"/e  subject,  see  E.  A.  Locke's  Food  Values,  Appleton  & 
Co.,  191-* — a  brief  and  admirable  book. 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

benzoate  of  soda  and  the  other  adulterations  about 
which  Dr.  Wiley  waged  such  a  contest  some  time  ago. 
There  is  no  evidence  that  in  the  amounts  used  they  do 
any  harm. 

This  ''purity"  question  has  an  importance  in  rela- 
tion to  fraud.  The  worst  adulteration  that  I  ever 
knew  about,  from  the  point  of  view  of  fraud,  was  used 
in  1898,  when  one  of  the  Chicago  packing-firms  sold 
to  the  United  States  Army  in  Cuba  a  lot  of  veal  loaf 
which,  when  investigated,  was  found  to  consist  of  corn 
meal  with  slight  traces  of  veal  here  and  there.  Now 
corn  meal  is  all  right  in  itself,  but  it  should  not  be  sold 
for  the  price  of  veal  loaf.  That  is  the  sort  of  basis  there 
is  in  most  of  the  talk  about  adulterated  foods. 

Some  of  the  substances  that  people  talk  about  as 
being  put  into  food  to  adulterate  it  are  so  much  more 
expensive  than  the  food  that  a  little  thought  will  set  us 
right  in  that  matter:  chalk  in  milk,  for  instance.  The 
only  thing  one  can  adulterate  milk  with  is  water,  be- 
cause it  is  the  only  thing  that  is  cheaper  than  milk. 

Now  as  to  distilled  water:  it  is  very  poor  stuff  to 
drink.  I  have  no  reason  to  suppose  it  will  ever  do 
any  harm,  because  it  is  too  nasty.  It  is  the  only  pure 
water,  and  the  only  water  that  no  one  will  ever  drink 
if  he  can  help  it.  It  is,  in  fact,  the  mineral  impurities  in 
ordinary  water  that  make  it  good  to  the  taste. 

There  are  certain  other  essentials  in  food  besides  the 
three  constituents  which  I  have  mentioned,  but  in  or- 
dinary life  we  usually  get  these  substances,  so  that  it  is 

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DIET  —  CONSTIPATION 

chiefly  when  one  is  on  shipboard  or  at  the  North  Pole 
that  the  question  of  scurvy  comes  up.  Of  course  in 
children  we  often  have  scurvy,  because  their  food  may 
be  very  one-sided  (unlike  the  adult's).  Scurvy  occurs 
in  those  who  do  not  have  any  fresh  food,  and  occurs 
for  the  lack  of  certain  substances  which  are  not  either 
carbohydrates,  proteids,  or  fats. 

These  substances  are  necessary  constituents  of  food ; 
about  them  we  know  very  little,  and  they  do  not  con- 
cern us  much,  but  it  is  well  to  know  the  name.  What  are 
called  vitamins  are  the  substances  in  our  food  whereby 
we  do  not  get  beri-beri.  Beri-beri  is  a  very  common  dis- 
ease in  Japan  and  the  Philippines,  where  people  eat 
rice.  It  practically  never  occurs  in  those  who  have  an 
ordinary  mixed  diet,  but  we  know  now  that  when  peo- 
ple live  on  rice  which  has  been  "polished,"  —  that  is, 
from  which  the  outer  layers  have  been  taken  off,  — 
they  get  beri-beri.  They  are  deprived  of  some  sub- 
stance which  we  know  very  little  about,  something 
which  is  not  carbohydrate,  proteid,  or  fat.  When  the 
polishings  removed  from  rice  are  fed  to  animals  with 
beri-beri,  the  beri-beri  gets  well.  This  unknown  x  in 
the  outer  layers  of  rice  is  called  vitamin.  Possibly  it  is 
the  lack  of  this  or  of  a  similar  substance  in  diet  that 
produces  scurvy  and  pellagra.  In  our  part  of  the 
world,  where  every  one  takes  a  mixed  diet,  the  ques- 
tion of  the  presence  or  absence  of  vitamins  does  not 
often  arise. 


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Shall  people  rest  after  food?  Seldom.  Rest  before 
food  is  much  more  important.  When  we  have  been 
working  hard,  either  with  mind  or  body,  the  blood 
gets  out  of  our  stomachs  into  our  muscles  and  brains. 
It  is  needed  there.  When  we  rest,  a  more  equal  dis- 
tribution through  the  body  takes  place,  and  the  stom- 
ach is  more  fit  to  do  its  job.  On  the  other  hand,  after 
meals  I  think  it  often  turns  out  that  people  digest  a 
little  better  by  not  keeping  still.  I  do  not  mean  that 
they  should  play  baseball  and  run  the  bases.  But  gen- 
tle exercise  after  a  meal  often  assists  digestion. 

We  also  have  to  consider  foods  more  or  less  with 
relation  to  bowel  activity  —  their  relation  to  consti- 
pation. Foods  tend  to  prevent  constipation  chiefly  in 
proportion  to  their  content  of  cellulose,  in  proportion 
to  their  content  of  undigested  residue,  which  stimu- 
lates the  intestine  to  push  its  contents  along.  It  is  for 
that  reason  that  we  take  the  so-called  coarse  bread,  rye 
or  whole  wheat,  such  substances  as  figs,  which  have 
considerable  residue,  or  such  substances  as  agar-agar. 
Cellulose  is  always  in  vegetable  foods.  There  is  no 
cellulose  in  any  other  food.  Carbohydrates  that  are 
not  combined  with  much  cellulose  digest  quickly; 
sugar  leaves  the  stomach  very  rapidly,  and  pure  starch. 
When  carbohydrates  contain  much  cellulose  they  leave 
the  stomach  more  slowly,  but  even  then  more  quickly 
than  the  proteids.  Fats  also  tend  to  prevent  constipa- 
tion. Any  one  who  has  dealt  with  children  knows  that 
in  constipated  children  we  try  to  add  fats  to  their  food. 

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DIET  —  CONSTIPATION 

It  is  not  quite  so  true  of  adults.    Knowing  what  the 
"fats"  are,  we  add  them  in  the  most  palatable  way. 

Questions  and  Answers 

Q.  How  early  do  you  give  solid  food  to  children? 

A.  At  about  two  years. 

Q.  When  a  person  is  very  tired  and  the  stomach  is  af- 
fected from  that,  would  you  let  him  indulge  in  eating? 

A.  Yes,  in  a  reasonable  period,  half  an  hour  or  an  hour 
after  that.  He  had  better  eat  unless  the  stomach  is  very 
actively  misbehaving. 

Q.  Do  you  believe  in  eating  when  you  have  a  headache? 

A.  I  should  not  always  stop  eating.  I  think  it  depends  on 
the  cause  and  the  intensity  of  the  headache  and  the  way  the 
patient  feels  in  other  respects.  If  you  have  a  really  sharp 
pain  in  your  head,  or  anywhere  else,  your  stomach  is  not 
likely  to  do  its  work  well  while  that  pain  lasts.  On  the  other 
hand,  most  of  us  have  seen  mild  headaches  go  off  as  soon 
as  food  is  put  into  the  stomach. 

Q.  What  about  foods  that  are  "heating"? 

A.  There  are  no  foods  that  are  heating.  No  food  pro- 
duces fever.  You  cannot  take  a  food  in  hot  weather  that 
will  make  you  hotter.  People  always  say,  in  summer  you 
must  not  take  heating  foods.  That  does  not  mean  anything. 
It  is  particularly  easy  to  overeat  in  summer,  and  this  may 
have  some  relation  to  that  tradition  about  foods  that  heat 
you.  In  a  cold  climate  when  you  are  putting  out  more  en- 
ergy, you  must  have  more  food.  The  reason  why  fatty  foods 
are  often  taken  by  Arctic  explorers  is  that  they  want  con- 
centrated nutrition  of  small  bulk.  Oil  and  sugar  are  very 
concentrated  foods. 

Q.  Are  colds  supposed  to  come  sometimes  from  upset 
stomach? 

A.  They  are  supposed  to,  but  they  don't.  Colds  come 
from  lack  of  sleep,  from  overwork,  from  depression  of  vital- 

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ity,  and  from  exposure  to  infected  patients.  There  are  times 
when  the  body  is  so  tired  righting  an  infection  that  the 
stomach  is  not  fit  to  do  much,  and  at  such  times,  if  we  are 
convinced  of  that,  we  had  better  not  eat.  The  doctor  should 
judge.  We  used  to  say,  "Stuff  a  cold  and  starve  a  fever." 
The  trouble  is  that  all  bad  colds  are  fevers.  If  the  cold  is 
a  very  short  infection,  you  may  accomplish  something  by 
starving  yourself;  but  if  it  is  going  to  last  any  time,  you 
certainly  must  eat,  and  in  all  the  long  fevers  we  now  order 
full  diet. 

Q.  With  high  blood  pressure  why  should  we  be  careful  as 
to  diet? 

A.  There  are  certain  foods  that  are  believed  to  raise  the 
blood  pressure.  I  do  not  think  the  evidence  is  very  good, 
but  it  is  the  prevailing  theory  that  meat  and  meat  extracts 
and  meat  soups  tend  to  raise  blood  pressure.  There  is  no- 
thing that  is  especially  important  as  to  diet  in  high  blood 
pressure  except  the  cutting-out  of  meat  and  meat  soups. 

Q.  Do  you  believe  in  very  regular  hours  for  meals? 

A.  I  believe  very  much  in  the  formation  of  habits  of  all 
kinds,  habits  of  mind  and  body.  I  believe  that  our  bodies 
go  a  good  deal  better  in  harness  and  in  routine ;  therefore  I 
believe  in  eating,  working,  and  sleeping  at  regular  times. 
Any  physician  who  is  called  in  the  early  morning  hours,  and 
eats  something  before  he  goes  out,  knows  that  the  effect  of 
this  may  be  indigestion.  The  stomach  often  does  not  do  a 
good  job.  It  is  not  accustomed  to  it  and  it  rebels.  There  is  a 
great  deal  in  the  rhythm  and  regularity  of  everything  we  do, 
and  I  am  sure  that  we  get  along  better  and  easier  by  eating 
regularly.  A  good  many  people  that  I  know  do  not  eat  any 
lunch.  A  few  people  that  I  know  eat  no  breakfast.  It  is  a 
question  of  idiosyncrasy.  The  main  thing  is  to  find  out  by 
experiment  your  own  best  way  and  then  cling  to  it.  There 
is  no  absolute  law  for  us  all. 

Q.  Is  there  any  truth  in  the  statement  that  a  person  who 
is  well  fed  is  less  apt  to  suffer  from  fatigue? 

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DIET  —  CONSTIPATION 

A.  Surely.  A  person  cannot  do  his  work  unless  he  is  well 
fed,  but  "well  fed  "  means  different  things  in  different  people, 
that  is,  my  necessary  rations  are  different  from  the  next 
person's. 

Q.  Is  there  anything  in  the  idea  that  we  all  need  fruit  and 
green  vegetables? 

A.  Except  in  relation  to  constipation,  I  have  never  seen 
anybody  who  suffered  from  the  lack  of  fruit.  Of  course,  if 
you  lack  all  fresh  food,  as  sailors  sometimes  do,  or  Arctic  ex- 
plorers, you  may  get  scurvy,  but  I  have  never  known  any 
one  on  an  ordinary  diet,  on  land,  who  suffered  from  lack  of 
the  salts  present  in  especially  large  percentages  in  certain 
vegetables. 

Q.  What  is  the  diet  in  rheumatism  and  kidney  trouble? 

A.  In  kidney  trouble  there  is  some  definite  knowledge. 
Many  people  with  kidney  trouble  tend  to  have  swelling  of 
the  body  —  dropsy  —  and  any  one  who  tends  to  have  dropsy 
should  not  eat  salt.  Salt  holds  water  in  the  body.  More- 
over, we  know  certain  spices  and  condiments  that  irritate 
the  kidney  and  we  cut  those  out.  I  will  come  back  to  that 
when  we  speak  of  kidney  trouble.  There  is  no  diet  either 
good  or  bad  for  rheumatism.  We  used  to  talk  of  avoiding 
acids,  because  we  formerly  believed  that  rheumatism  was 
due  to  too  much  acid  (especially  uric  acid)  in  the  body.  I 
remember  a  dramatic  professor  of  medicine  who  brought  out 
a  piece  of  blue  litmus  paper,  which  you  know  turns  red  when 
you  put  it  into  an  acid.  He  dipped  the  blue  in  a  rheumatic 
patient's  sweat,  showed  the  change  to  red,  and  said,  "You 
see,  the  acid  sweat  of  rheumatism!"  Of  course,  if  he  had 
tried  the  sweat  that  was  rolling  down  his  own  brow,  the 
result  would  have  been  the  same.  There  is  nothing  in  the 
acid  theory  of  rheumatism,  and  nothing  in  the  diet  based 
upon  it. 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

Constipation 

In  adults  constipation  is  usually  a  disease  of  the 
brain  —  in  other  words,  a  result  of  nervousness.  It  is 
rarely  a  disease  of  the  intestine,  and  in  the  vast  major- 
ity of  cases  nothing  is  found  wrong  with  the  intestine. 
In  only  a  minority  of  cases  it  arises  from  wrong  diet; 
it  is  generally  due  to  wrong  thoughts  and  emotions. 
Every  time  there  is  a  stock-market  panic  the  stock- 
brokers run  to  their  doctors  for  constipation.  Every 
time  a  person  has  any  great  emotional  strain,  fear, 
worry,  etc.,  he  is  liable  to  be  constipated.  Women  are 
more  constipated  than  men,  because  their  emotional 
life  is  more  intense  and  more  complex.  We  used  to  ex- 
plain it  by  the  fact  that  they  were  more  sedentary, 
but  that  cannot  be  the  fact. 

The  fundamental  cure  of  constipation  is  difficult, 
because  there  is  nothing  so  tough  as  a  mental  habit.  It 
is  one  of  the  hardest  of  all  things  to  change,  —  much 
harder  than  a  physical  habit  usually,  —  but  it  can  be 
overcome,  and  I  have  yet  to  see  a  single  case  of  con- 
stipation that  cannot  be  cured  by  mental  means  alone. 
We  often  do  not  try  to  cure  the  trouble  that  way  be- 
cause it  takes  too  much  time,  but  it  can  be  done. 

Dr.  Cannon,  whom  I  have  quoted  so  frequently  be- 
cause he  is  the  source  of  almost  all  the  modern  knowl- 
edge of  the  stomach  and  the  intestine,  made  some  very 
important  observations  on  this  subject.  When  work- 
ing on  a  cat,  and  watching  with  X-ray  the  movements 

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DIET  —  CONSTIPATION 

of  its  intestine  rendered  visible  by  giving  the  cat  bis- 
muth, a  dog  barked  near  the  laboratory  one  day,  and 
to  his  great  astonishment  he  found  that  the  cat's  fear 
manifested  itself  in  immobility  of  the  intestines.  He 
could  not  continue  his  experiment  for  some  hours,  be- 
cause the  cat's  intestine  had  stopped  work  altogether. 
The  rhythmic  movements  in  the  intestine  had  ceased 
because  of  the  psychic  inhibition — fear.  Most  human 
beings  are  more  highly  organized  than  most  cats,  and 
emotional  disturbance  which  will  affect  a  cat's  intes- 
tine will  affect  a  human  intestine  still  more.  Emotional 
habits  get  into  the  intestine  and  stick  there  very  firmly. 
Next  to  emotion  as  a  cause  of  constipation,  the  most 
important  thing  is  bad  habits;  that  is,  lack  of  regular- 
ity. We  are  creatures  of  habit  to  a  degree  that  we  do 
not  ordinarily  realize.  I  think  one  of  the  most  striking 
cases  of  this  is  what  happens  to  us  on  board  ship, 
if  the  question  of  sea-sickness  does  not  come  up.  In 
the  middle  of  the  morning  the  steward  brings  around 
something  to  eat.  We  have  just  finished  breakfast,  and 
we  say,  "  No,  certainly  not."  The  second  day  we  take 
what  he  brings  —  nothing  else  to  do.  But  about  the 
sixth  day,  if  the  steward  does  not  come  on  the  dot,  we 
are  much  annoyed.  Within  a  week  the  stomach  has 
absolutely  changed  its  habits.  It  feels  insulted  if  the 
food  does  not  turn  up.  That  shows  how  quickly  a 
harmless  habit  can  be  formed.  In  the  same  way  a 
wrong  habit  can  be  formed  very  quickly  and  may  be 
very  difficult  to  break.  People  should  have  an  abso- 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

lutely  cast-iron  rule  about  the  time  of  day  when  their 
bowels  move.  It  is  the  experience  of  hundreds  of  hu- 
man beings  that  if  they  are  suddenly  called  away  in  the 
morning  before  having  their  regular  movement,  they 
cannot  again  at  any  other  time  that  day  have  a  move- 
ment. That  is  one  of  the  numerous  examples  of  the 
force  of  habit.  A  working  woman  of  my  acquaintance 
found  that  it  was  more  convenient  to  have  her  bowels 
move  in  the  evening,  and  so  trained  her  bowels  in  that 
way.  It  can  be  perfectly  well  arranged  at  any  time  of 
day,  the  whole  point  being  that  it  should  be  the  same 
time  of  day. 

Any  process  that  ought  to  go  on  unconsciously  can 
be  hampered  by  keeping  the  mind  on  it;  this  is  also 
true  of  movements  of  the  intestine.  People  have  dif- 
ficulty who  get  worried  over  the  movements  and  are 
trying  particularly  hard.  Many  men  get  over  this  diffi- 
culty by  smoking;  it  turns  their  thoughts  in  other  di- 
rections. Other  people  use  reading  for  the  same  pur- 
pose. The  main  thing  is  to  prevent  the  mind  doing 
harm  in  interfering  in  a  direction  where  it  does  not 
belong.  The  whole  process  should  be  almost  instinctive 
and  automatic  once  the  habit  is  formed. 

Medicines  used  for  constipation  are  very  many  and 
most  of  them  very  harmless.  One  should  distinguish 
(and  make  others  distinguish)  between  "  laxatives " 
and  "purgatives."  A  laxative  is  a  medicine  of  mild 
action  which  can  be  taken  over  a  long  period  without 
any  harm.  A  purgative  is  a  medicine  of  relatively 

134 


DIET  —  CONSTIPATION 

violent  action,  which  empties  the  bowel  out  instead  of 
simply  moving  its  contents  along  a  little  faster.  Purga- 
tives are  never  to  be  used  steadily.  They  have  their 
place  like  morphine,  as  a  rare  occasional  drug. 

Laxatives  often  used  are  cascara,  licorice  powder, 
rhubarb,  senna,  phenolphthalin,  agar  agar,  and  the 
aloin,  strychnia,  and  belladonna  pills,  ordinarily 
known  both  to  physicians  and  patients  as  an  "  A.  S.  & 
B."  These  are  the  commonest  mild  laxatives.  They 
are  all  things  that  people  have  taken  without  any 
special  harm  that  we  can  see,  for  years  and  years,  but 
they  often  lose  their  power. 

The  mineral  oil  so  much  used  now  is  usually  called 
1  'Russian  Oil,"  but  is  simply  liquid  petroleum  in  an 
available  and  not  very  disagreeable  form ;  it  is  a  useful 
laxative. 

Purgatives  are  such  medicines  as  magnesium  sul- 
phate, the  ordinary  "salts"  (Jewish  patients  call  them 
"  bittersaltz  "  —  a  good  thing  to  know  in  talking  with 
such  patients),  and  the  compound  cathartic  pill  for 
which  surgeons  have  a  special  fondness  for  their  pa- 
tients;  mercury  in  the  form  of  calomel  or  blue  pill, 
and  jalap.  There  is  only  one  purgative  that  can  be 
given  to  an  unconscious  patient,  and  that  is  croton 
oil,  a  drop  or  two  of  which  on  the  tongue  in  an  un- 
conscious patient  will  sometimes  produce  purgation. 

Of  the  use  of  laxatives  this  is  to  be  said:  a  person 
who  uses  laxatives  never  gets  rid  of  constipation;  his 
bowels  never  get  into  order  of  themselves.  On  the 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

other  hand,  there  are  a  good  many  people  who  can 
take  laxatives  for  years  without  having  to  increase  the 
dose,  without  the  medicines  losing  their  effect,  and 
without  any  harm  that  we  can  see.  In  most  of  those 
people  I  believe  the  drug  acts  through  suggestion,  not 
on  the  bowel  but  on  the  brain;  but  it  is  hard  to  prove 
that.  People  come  to  a  doctor  sometimes  for  constipa- 
tion who  are  getting  on  perfectly  with  some  laxative, 
but  are  scared  of  its  effects  and  have  to  be  reassured 
that,  so  long  as  it  works,  and  they  do  not  have  to  in- 
crease the  dose,  there  is  no  reason  why  they  should  not 
take  it  for  forty  or  fifty  years  more. 

The  effects  of  constipation  vary  enormously.  In 
certain  people  there  are  no  effects.  People  may  go 
without  a  bowel  movement  for  weeks  without  any  ill 
effects.^It  is  hard  to  believe,  but  it  is  true.  On  the 
other  hand,  there  are  many  more  people  who,  if  they 
skip  a  single  day,  feel  headache  and  dull,  dragging  tire. 
I  do  not  know  how  to  explain  these  differences.  A  good 
many  serious  diseases  or  symptoms  are  attributed, 
quite  falsely,  I  think,  to  constipation.  I  do  not  think 
there  is  any  reason  to  suppose  that  it  has  any  serious 
effect  of  any  kind.  Quite  annoying  hemorrhoids  often 
accompany  constipation  and  are  seldom  relieved  until 
that  is  relieved. 


CHAPTER  VI 

DISEASES  OF   THE  LIVER  AND  INTESTINE 
j.   Diseases  of  the  Liver 

THE  liver  is  rarely  diseased.  Patients  tell  you  a  great 
deal  about  their  livers,  and  appear  to  have  a  great  deal 
of  knowledge  about  them,  but  physicians  know  very 
little  about  them,  and  in  fact  the  liver  is  seldom  dis- 
eased. People  are  always  telling  us  that  they  have  a 
''torpid  liver,"  and  I  used  to  be  quite  eager  to  know 
what  that  was,  and  have  them  tell  me  what  that  was, 
but  I  have  still  to  remain  ignorant  about  it.  Or  people 
tell  us  that  they  are  "bilious,"  which  again  they  refer 
to  their  livers ;  when  we  dig  out  what  they  mean  it  has 
never  anything  to  do  with  the  liver.  So  far  as  I  know, 
"biliousness"  means  constipation,  and  "torpid  liver" 
means  the  same.  These  are  terms  known  only  to  pa- 
tients. One  is  apt  to  be  told,  "Oh,  yes,  I  have  to  take 
such  a  drug  for  my  liver";  or,  "This  drug  works  very 
well  on  my  liver."  But  there  are  no  such  drugs.  Cal- 
omel, for  instance,  is  generally  supposed  to  work  upon 
the  liver,  but  has  no  such  effect  whatever. 

Two  important  diseases  in  or  near  the  liver  are  gall- 
stones and  cirrhosis.  Gall-stones  are  common,  but  they 
are  rarely  formed  in  the  liver  itself,  and  are  therefore 
no  contradiction  to  what  I  have  just  said.  Gall-stones 
are  actual  stones,  and  constitute  one  of  many  examples 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

of  the  curious  habit  of  the  body  to  form  stones  in  the 
wrong  place.  The  body  forms  stones  in  our  skeleton; 
that  is  forming  stones  in  the  right  place.  But  it  also 
forms  stones  in  a  great  man}'  places  where  they  do 
harm.  So  far  as  we  know,  it  is  an  effort  on  the  part  of 
nature  to  do  good ;  but  sometimes  it  is  a  mistaken  ef- 
fort. How  wonderful  are  the  things  that  nature  does, 
but  also  how  wrong-headed  every  now  and  then! 
This  process  of  building  stones  in  the  body  may  save 
our  lives.  There  is  a  beautiful  example  of  this  use  in 
diseases  of  the  lungs.  Probably  more  than  half  of  us 
have  at  some  time  had  tuberculosis  in  our  lungs  and 
have  got  over  it  altogether.  When  it  heals  it  is  often 
because  the  focus  of  live  bacilli  is  actually  walled  in 
by  a  stone,  so  that  when  the  lung  is  cut  after  death 
the  knife  rasps  on  this  stone.  But  nature  does  a 
great  deal  of  harm  by  forming  stones  in  the  gall- 
bladder. 

Stones  in  the  gall-bladder  are  the  end  result  of  in- 
flammation in  the  gall-bladder,  just  as  in  the  lung  they 
are  the  end  result  of  tuberculous  inflammation  in  the 
lung;  but  in  the  gall-bladder  they  do  no  good,  so  far  as 
we  know,  and  certainly  do  harm.  They  may  be  as  big 
as  a  pin-head  or  as  big  as  a  hen's  egg,  and  there  are 
usually  many  of  them  of  the  size  of  a  pea  or  larger  in 
the  gall-bladder  when  there  are  any  at  all.  The  gall- 
bladder is  about  the  size  of  an  ordinary  watch-pocket, 
and  as  long  as  the  gall-stones  stay  in  there  they  do  no 
harm.  A  considerable  number  of  all  the  bodies  ex- 

138 


DISEASES  OF  THE  LIVER 

amined  at  autopsy  show  gall-stones  in  people  who 
never  had  a  symptom  from  them.  It  is  only  when  they 
try  to  get  out  of  the  gall-bladder  that  they  make 
trouble.  The  gall-bladder  has  a  tube  leading  from  it, 


(T)  ^O^L  SSo-dctu.    f  tOKC/^cu  £""" 

L  __ 


its  own  duct,  which  is  joined  by  another  duct  coming 
down  from  the  liver,  and  these  two  unite  to  form  a 
common  duct  which  leads  to  the  duodenum;  but  just 
before  it  reaches  the  duodenum  this  common  duct 
joins  another  duct  coming  from  the  pancreas. 

Bile  comes  down  from  the  liver,  goes  up  into  the 
gall-bladder,  and  is  stored  there,  runs  down  the  com- 
mon duct  to  the  duodenum,  is  mixed  with  the  food, 

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A  LAYMAN'S  HANDBOOK  OF^  MEDICINE 

and  assists  in  a  mild  way  with  the  digestion.  We  can 
get  along  fairly  well  without  it.  Stones,  so  long  as  they 
remain  in  the  gall-bladder,  usually  do  no  harm;  but 
every  now  and  then  they  get  stuck  in  the  cystic  or  the 
common  duct,  and  then  we  have  trouble,  which  ex- 
presses itself  in  the  majority  of  cases  in  what  is  called 
biliary  colic,  or  gall-stone  colic. 

This  is  one  of  the  two  diseases  that  I  think  social 
workers  and  laymen  generally  ought  to  know  the  his- 
tory of  in  detail,  because  the  diagnosis  depends  almost 
entirely  on  the  history.  Peptic  ulcer  and  gall-stone 
disease  are  diagnoses  often  made  without  much  help 
from  physical  examination.  Gall-stone  colic  is  the 
severest  pain  that  most  individuals  who  have  it  have 
ever  had.  It  usually  comes  on  in  the  night,  waking  the 
person  from  sleep,  but  it  may  come  at  any  time.  Of 
all  pains  that  we  hear  about  it  is  most  apt  to  require 
morphine,  so  that  in  taking  the  history  of  such  a  pa- 
tient we  always  ask,  "Have  you  had  morphine  given 
you  for  this  abdominal  pain?  "  and  if  one  finds  that  mor- 
phine has  been  given,  that  is  a  certain  amount  of  evi- 
dence that  the  pain  is  due  to  gall-stones.  Morphine  is 
a  blessing  for  this  disease,  for  it  will  often  stop  an  at- 
tack, and  after  an  attack  a  person  may  not  suffer  again 
for  weeks,  months,  or  even  years.  The  pain  is  usually 
at  the  pit  of  the  stomach  and  not  over  the  liver,  which 
is,  of  course,  to  the  right  of  that  point.  From  there  pain 
shoots  to  the  back  and  to  the  right  shoulder  and  shoul- 
der-blade. It  lasts  from  an  hour  to  eight  or  ten  hours. 

140 


DISEASES  OF  THE  LIVER 

Its  average  duration  we  cannot  tell  very  well,  because  it 
is  usually  checked  by  morphine ;  without  that  it  might 
go  on  longer,  perhaps,  but  not  more  than  a  few  days. 
When  it  stops  the  patient  is  all  right  except  for  the 
exhaustion  of  the  pain.  It  is  apt  to  be  accompanied 
or  followed  by  chill,  fever,  jaundice,  and  vomiting. 

Now,  for  contrast,  we  may  profitably  compare  this 
with  the  pain  of  peptic  ulcer.  The  pain  of  peptic  ulcer 
is  a  pain  which  comes  when  the  stomach  is  empty,  three 
times  a  day,  relieved  by  food,  rarely  very  sharp,  a  pain 
that  does  not  need  morphine,  that  is  not  accompanied 
by  fever  or  chill,  that  usually  does  not  lead  to  vomiting. 
On  the  other  hand,  the  gall-bladder  pain  is  not  a  regu- 
lar daily  occurrence,  but  a  single  attack,  coming  usu- 
ally at  night,  with  no  relation  to  food,  very  intense, 
needing  morphine  for  its  relief,  radiating  to  the  back 
and  the  right  shoulder,  and  often  accompanied  by 
fever,  chill,  and  vomiting. 

Relief  from  morphine  probably  results  because  the 
morphine  relaxes  everything  in  the  body,  and  with 
that  relaxes  the  grip  of  the  duct  upon  the  stone  so 
that  the  stone  can  slide  back  into  the  gall-bladder.  If 
morphine  is  not  given,  the  stone  may  pass  down  into 
the  duodenum  or  back  into  the  gall-bladder.  People 
writhe  with  pain  from  the  unconscious  effort  to  get 
their  bodies  into  some  queer  position,  and  so  to  ease 
themselves  or  perhaps  to  shake  the  stone  back  into 
the  gall-bladder.  They  find  that  they  are  liable  to  get 
into  a  position  where  something  lets  up.  Biliary  colic 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

is  a  pain  of  which  people  often  say  that  it  "  doubles 
them  up,"  or  that  they  writhe,  or  that  "you  can 
hear  them  shout  for  two  blocks."  It  is  never  fatal, 
not  in  itself  dangerous,  only  agonizing.  Operation 
is  done  because  the  stone  may  lead  to  more  serious 
results. 

According  to  where  the  stone  is  placed  we  do  or  do 
not  have  jaundice.  Jaundice  is  a  yellow  staining  of  the 
eye  and  skin  by  bile  retained  in  the  blood  because  it  has 
not  passed  down  into  the  duodenum ;  it  is  absorbed  into 
the  blood  and  thence  deposits  itself  in  the  eyes  and  in 
the  skin,  and  finally  in  the  urine,  making  that  dark.  If 
the  stone  is  in  the  cystic  duct  (see  Fig.  29),  the  duct 
leading  to  the  gall-bladder,  the  bile  passes  straight 
down  into  the  intestine  and  there  is  no  jaundice.  But  if 
the  stone  is  in  the  common  duct  or  the  hepatic  duct,  it 
interferes  with  the  passage  of  bile  and  we  have  jaundice. 
In  different  attacks  we  may  with  one  have  jaundice 
and  with  another  have  none,  according  to  the  position 
of  the  stone.  If  the  stone  gets  fixed  in  the  common  duct, 
the  commonest  position,  we  have  jaundice,  which  is  a 
troublesome  and  more  or  less  serious  thing.  Then 
there  arises  an  inflammation  of  that  duct  from  the  ir- 
ritation of  the  stone,  which  inflammation  may  pass  up 
into  the  liver  itself  and  there  may  produce  abscesses, 
which  are  often  fatal.  Or  the  stone  may  ulcerate 
through  the  side  of  the  duct,  producing  peritonitis, 
also  frequently  a  fatal  disease.  These  are  the  two  con- 
sequences of  gall-stones  which  we  fear,  and  by  reason 

142 


DISEASES  OF  THE  LIVER 

of  which  we  advise  operation  when  a  person  has  had 
many  attacks.  I  do  not  think  anybody  knows  how 
long  a  time  a  stone  may  be  there  without  causing  ulcer; 
probably  a  long  time,  but  we  do  not  know  how  long. 

We  cannot  dissolve  the  stones  or  do  anything  for 
them  except  relieve  pain.  The  treatment,  therefore, 
is  surgery  or  nothing.  If  the  symptoms  are  not  bad 
enough  to  demand  surgery,  there  is  nothing  one  can 
do,  and  the  patient  might  as  well  save  his  money. 

Dr.  Bigelow,  one  of  the  old-time  worthies  and  honors 
of  the  Massachusetts  General  Hospital,  stated  the 
cause  or  causative  factors  of  gall-stones  more  tersely 
than  it  has  ever  been  done  before  or  since:  "They 
occur  in  fat  old  women."  But  thin  young  men  are  not 
absolutely  exempt  —  nor  any  one  else. 

The  only  other  thing  we  know  about  their  cause  is 
that  they  often  follow  typhoid  fever.  The  typhoid 
bacillus  gets  into  the  gall-bladder  and  presumably 
causes  a  low-grade  inflammation  there.  Then  nature 
gets  busy  trying  to  squelch  that  inflammation,  and 
builds  a  wall  around  the  bacilli.  There  results  a  stone 
which  often  gives  trouble.  When  we  cut  open  these 
stones  we  may  find  a  live  typhoid  bacillus,  even  thirty- 
five  years  after  an  attack,  as  in  one  case,  —  shut  up 
there,  harmless,  but  at  a  great  price  to  the  body. 

We  advise  operation  in  gall-stones  whenever  a  per- 
son has  had  many  attacks,  and  for  the  reason  given, 
namely,  that  we  have  no  other  treatment,  and  that 
there  are  dangers  in  the  continued  presence  of  gall- 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

stones  in  the  ducts,  and  some  danger  even  if  the  stone 
remains  in  the  gall-bladder  itself. 

A  successful  operation  by  a  skilful  surgeon  is  a  sure 
cure  for  those  stones.  Gall-stone  operations  are,  with 
one  or  two  exceptions,  the  most  difficult  operations  in 
surgery.  There  are  relatively  few  surgeons  who  are 
capable  of  doing  them  well.  Operation  is  a  cure  of  the 
stones  taken  out  at  that  time,  but  a  recurrence  is  pos- 
sible, and  in  something  like  ten  per  cent  of  cases  stones 
form  again.  The  effect  on  the  body  if  the  gall-bladder  is 
taken  out  is  good.  We  have  no  use  for  the  gall-bladder ; 
it  was  apparently  a  mistake.  In  many  operations  it  is 
taken  out.  But  owing  to  the  build  of  the  individual  it 
is  sometimes  very  difficult  to  reach.  The  surgeon  may 
have  to  go  through  six  inches  of  fat  to  get  there. 

Gall-stone  disease  is  often  taken  for  stomach  trouble. 
I  have  had  the  practice  for  years  of  writing  down  in  my 
records  what  the  patient  first  complains  of,  and  when 
the  patient  comes  for  "stomach  trouble"  in  about  ten 
per  cent  of  cases  she  has  gall-stones  —  that  is,  the  pain 
has  been  misinterpreted. 

If  gall-stones  are  too  big  to  get  into  one  of  the  ducts, 
as  a  rule  we  do  not  have  pain,  but  in  most  cases  there 
are  a  number  of  small  stones.  Once  in  a  while  a  single 
large  stone  ulcerates  clear  through  the  gall-bladder.  It 
may  ulcerate  into  the  intestine.  The  gall-bladder  first 
glues  itself  to  the  intestine  and  then  the  stone  ulcerates 
through.  I  saw  an  autopsy  recently  on  a  patient  whose 
intestine  was  blocked  by  a  gall-stone. 

144 


DISEASES  OF  THE  LIVER 

I  spoke  of  the  important  relation  of  two  ducts:  (a) 
the  common  duct  uniting  those  from  the  gall-bladder 
and  from  the  liver;  and  (b)  the  pancreatic  duct.  A 
stone  may  get  wedged  into  a  position  such  as  to  shunt 
the  bile  into  the  pancreas.  The  bile,  instead  of  running 
down  into  the  intestine,  runs  against  the  stone,  turns, 
and  goes  up  into  the  pancreas.  There  it  becomes  the 
cause  of  a  very  acute  and  serious  disease,  pancreatitis, 
inflammation  of  the  pancreas.  It  is  so  acute  and  usu- 
ally so  fatal  that  there  is  almost  no  provision  to  be 
made  for  the  individual  and  death  often  results.  I 
mention  this  as  one  of  the  dangers  of  gall-stones.  See 
Fig.  29. 

Cirrhosis.  The  only  other  important  disease  of  the 
liver  is  cirrhosis.  " Cirrhosis"  is  a  very  bad  term.  It 
means  "tawny-colored,'*  because  the  liver  in  this  dis- 
ease was  supposed  to  get  tawny-colored.  Cirrhosis  is 
really  a  hardening  and  contraction  of  the  liver  due  to 
millions  of  scars,  those  scars  themselves  due  to  irrita- 
tion, probably  from  alcohol  plus  x.  Alcohol  alone  is 
not  enough  to  do  it.  We  cannot  produce  it  experimen- 
tally in  animals  with  alcohol.  At  the  same  time  almost 
every  patient  that  has  it  is  alcoholic.  Probably  there  is 
some  unknown  factor  which  combines  with  alcohol, 
causes  that  inflammation,  and  produces  these  scars 
which  harden  and  contract  the  liver.  It  is  one  of  the 
most  serious  results  of  alcoholism.  The  most  serious 
result  is  mental  and  cerebral  degeneration,  changes  in 
the  mind.  But  next  to  that,  cirrhosis  of  the  liver  is  the 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

most  important  evil  result  of  alcohol,  for  it  is  an  inva- 
riably fatal,  though  rather  slowly  fatal,  disease.  As  the 
liver  becomes  smaller  it  gradually  becomes  so  hard  that 
the  blood  cannot  pass  through  it.  The  venous  blood 
coming  from  the  intestines  has  to  pass  through  the 
liver  before  it  gets  back  to  the  heart.  If,  then,  the  liver 
is  blocked  by  the  contraction  of  innumerable  scars,  the 
blood  stagnates  in  the  veins  of  the  abdomen  and  we 
have  the  usual  result  of  stagnation,  dropsy.  The  serum 
oozes  from  the  blood  vessels  and  accumulates  in  the 
peritoneal  cavity.  That  is  called  ascites  —  the  accumu- 
lation of  fluid  in  the  peritoneal  cavity,  whereby  we  see 
an  unfortunate  individual  whose  arms  and  legs  are 
very  meagre,  and  who  has  an  enormous  abdomen.  We 
put  in  a  hollow  needle,  draw  off  the  fluid,  and  relieve 
the  individual  for  a  few  weeks.  Then  the  fluid  reaccu- 
mulates,  and  so  on.  Every  time  that  we  tap,  although 
we  relieve  the  patient  of  the  pressure  and  discomfort  of 
the  fluid,  we  take  out  a  very  valuable  fluid  which  he 
cannot  well  spare,  and  the  loss  of  which  gradually  weak- 
ens him  until  he  dies. 

Death  sometimes  comes  in  cirrhosis  of  the  liver  from 
vomiting  of  blood.  The  veins  that  leave  the  stomach, 
some  of  them,  drain  into  the  liver.  If  the  liver  is  blocked 
so  that  the  blood  cannot  pass  through  it,  the  blood 
stagnates  in  the  stomach  until  a  vessel  breaks  and  we 
have  bleeding  and  vomiting  of  blood  which  may  be 
fatal. 

In  this  disease,  as  in  so  many  other  long-standing 

146 


DISEASES  OF  THE  LIVER 

diseases,  the  patient  often  becomes  weaker  and  weaker, 
then  catches  some  acute  infection,  such  as  pneumonia 
or  tuberculosis,  and  cannot  withstand  it.  He  usually 
dies  of  what  we  call  a  "  terminal  infection,"  a  swarm- 
ing in  of  bacilli  which  he  ordinarily  would  resist,  but 
which  in  his  weakened  condition  he  cannot.  The  dis- 
ease probably  lasts  many  years,  but  we  do  not  ordi- 
narily know  of  its  existence  until  within  the  last  year 
or  two  of  life.  The  patient  is  never  able  to  work  much 
after  ascites  appears. 

Abscess  of  the  liver  is  very  common  in  tropical  coun- 
tries because  of  the  migration  of  the  germs  of  some  of 
the  tropical  diseases  up  through  the  intestine  by  the 
blood  stream  into  the  liver.  In  the  southern  part  of 
this  country,  and  in  all  tropical  countries,  we  have 
amoebic  dysentery,  dysentery  coming  from  amoebae. 
It  results  often  in  the  transfer  of  amoebae  up  through 
the  intestine  to  the  liver,  and  the  formation  of  abscesses 
there.  All  tropical  countries  have  amoebic  dysentery 
and  liver  abscess.  We  do  not  see  this  type  of  liver 
abscess  here  except  in  occasional  cases  brought  in  from 
other  countries,  as  from  Central  America  or  there- 
abouts. It  can  be  operated  on  and  cured  in  many  cases. 
Abscess  of  the  liver  may  also  be  due  to  appendicitis  or 
to  gall-stones. 

Those  persons  who  associate  very  widely  with  sheep 
and  sheep  dogs,  such  as  the  inhabitants  of  Iceland, 
Australia,  and  Greece,  are  often  afflicted  with  another 
disease  of  the  liver,  hydatid,  a  parasite  which  they  get 

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from  the  sheep  or  the  sheep  dogs,  and  which  forms 
enormous  bladder-like  cysts  in  the  liver.  We  see  it 
here  every  now  and  then  in  Greeks.  It  never  occurs 
in  this  country  unless  imported,  and  it  is  so  rare  that 
it  is  not  of  any  great  importance  to  us. 

A  word  about  ordinary,  so-called  "catarrhal  jaun- 
dice" A  painless  jaundice,  well  in  a  few  weeks,  is 
usually  catarrhal  jaundice,  an  acute  inflammation  of 
the  bile  ducts  whereby  they  close  for  a  time.  The  bile 
cannot  pass  down;  therefore  it  comes  back  into  the 
blood  and  the  patient  becomes  jaundiced.  This  lasts 
from  two  to  six  weeks.  If  it  lasts  longer  it  usually  is 
not  "catarrhal  jaundice,"  but  a  jaundice  due  to  gall- 
stones or  cancer. 

Catarrhal  jaundice  gets  well  of  itself.  Medicines 
make  no  difference.  It  is  uncomfortable,  but  that  is  all. 
The  patient  is  generally  blue  mentally,  although  yellow 
cutaneously,  and  needs  the  visits  of  his  friends  more 
than  of  his  doctor. 

Cancer  of  the  bile-duct  produces  a  persistent,  usu- 
ally painless,  but  intense  jaundice,  lasting  months  and 
terminating  fatally.  It  usually  occurs  —  like  cancer 
elsewhere  —  after  middle  life.  There  is  no  treatment. 

Cancer  of  the  liver  itself  is  usually  a  late  complica- 
tion and  extension  of  stomach  cancer.  It  is  usually 
painless  and  always  4iopeless. 

Tuberculosis  rarely  affects  the  liver.  Syphilis  occurs 
there  as  it  does  everywhere,  but  there  is  no  especial 
reason  for  going  into  that. 

148 


DISEASES  OF  THE   INTESTINE 

Remember,  then,  that  the  liver  is  very  rarely  dis- 
eased, and  that  its  only  common  disease  of  great  prac- 
tical importance  is  gall-stones,  because  this  is  almost 
the  only  liver  disease  that  we  can  do  anything  about. 

2.  Diseases  of  the  Intestine. 

Without  any  question  the  most  important  disease  of 
the  intestine  is  appendicitis,  a  disease  discovered  by  a 
physician  of  the  Massachusetts  General  Hospital,  Dr. 
R.  H.  Fitz,  some  thirty  years  ago.  The  appendix  is 
like  the  little  finger  of  a  glove,  and  hangs  off  from  the 
point  where  the  small  intestine  joins  the  large;  it  has  no 
use  whatever.  We  do  not  know  the  cause  of  appendici- 
tis, but  there  are  good  reasons  for  suspecting  that  some 
cases,  if  not  all,  are  due  to  a  streptococcus.  Streptococ- 
cus disease,  the  same  thing  that  we  have  as  tonsillitis, 
the  same  thing  that  causes  so  much  heart  disease  and 
kidney  disease,  is  now  suspected  to  be  the  cause  of  some 
cases  of  appendicitis.  Only  in  a  very  indirect  way 
could  wet  feet  have  any  relation  to  appendicitis.  Wet 
feet  may  be  part  of  a  general  chilling  of  the  body,  chill- 
ing of  the  body  reduces  vitality,  any  reduction  of  vi- 
tality makes  germs  happy.  Appendicitis  comes  often- 
est  in  young  people  at  the  age  when  all  streptococcus 
disease  is  most  apt  to  strike,  and  I  have  seen  a  group 
of  cases  which  immediately  followed  tonsillit^. 

Appendicitis  is  commoner,  then,  in  young  people, 
and  commoner  in  men  than  in  women.  It  attacks 
people  in  perfect  health  as  well  as  people  who  are  run 

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down.  If  anybody  took  the  contract  to  prevent  ap- 
pendicitis he  would  lose  money  by  it.  We  have  not 
any  idea  how  to  prevent  it  to-day. 

Many  who  know  nothing  else  of  anatomy  know 
that  the  appendix  is  halfway  along  an  imaginary  line 
drawn  from  the  navel  to  the  hip  bone  (felt  as  one  puts 
the  hand  upon  the  hip  in  front).  The  middle  of  that 
line  is  the  base  of  the  appendix,  in  the  space  called 
the  "right  iliac  fossa."  (Fossa  means,  literally,  ditch. 
Iliac  means  near  the  big  bone  that  we  call  the  ilium.) 
The  earliest  pain  from  appendicitis  is  usually  not  over 
the  appendix,  but  in  the  middle  line,  at  the  pit  of  the 
stomach.  That  is  one  of  the  reasons  why  we  often  fail 
to  recognize  it.  But  the  tenderness  of  appendicitis  — 
that  is,  the  pain  on  pressure  —  is  usually  over  the  ap- 
pendix itself.  Nothing  worse  could  happen  to  us,  or 
to  any  one  whom  we  influence,  than  to  suppose  that 
all  pain  in  the  right  iliac  fossa  means  appendicitis. 
There  are  a  vast  number  of  pains  in  that  region,  con- 
nected with  constipation,  with  menstruation,  with 
muscular  strains,  and  other  slight  indispositions.  Only 
those  pains  in  the  right  iliac  fossa  are  serious  which  are 
accompanied  by  tenderness,  by  slight  fever,  rapid 
pulse,  and  usually  by  changes  in  the  blood.  There  are  a 
great  many  lay  diagnoses  of  appendicitis.  Yet  it  may 
be  one  of  the  most  difficult  diagnoses  that  a  physician 
ever  makes,  and  one  that  a  layman  should  be  very 
slow  to  make.  Chills  are  rather  an  uncommon  symp- 
tom ;  chills  depend  upon  high  fever,  and  the  fever  in 

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DISEASES  OF  THE   INTESTINE 

appendicitis  is  usually  not  high  but  moderate,  usually 
100.5°  or  less.  Pain,  vomiting,  tenderness,  rapid  pulse, 
fever,  changes  in  the  blood,  and  the  peculiar  feeling, 
which  the  physician  appreciates,  in  the  abdomen  over 
the  appendix,  —  these  are  the  chief  diagnostic  points* 

From  the  layman's  point  of  view  one  of  the  most  im- 
portant things  is  to  distinguish  genuine  acute  appendi- 
citis from  the  many  things  called  "  chronic  appendi- 
citis." Acute  appendicitis  is  a  well-known,  well-studied, 
very  important  disease,  and  anybody  who  has  had  more 
than  one  attack  of  it  ought,  I  think,  to  have  the  ap- 
pendix out.  Chronic  appendicitis  is  a  disease  the  very 
existence  of  which  some  of  us  doubt ;  it  is  poorly  under- 
stood if  it  does  exist,  and  a  person  may  well  have  it 
throughout  his  life  and  never  find  it  out.  We  should  in- 
fluence anybody  we  know  to  have  an  operation  done  if 
he  has  had  more  than  one  attack  of  acute  appendicitis, 
but  use  any  influence  we  have  toward  caution  and  ex- 
pert diagnosis  for  any  one  who  is  said  to  have  chronic 
appendicitis.  Chronic  appendicitis  does  not  have  the 
symptoms  that  I  have  described,  and  each  doctor  that 
we  ask  to  describe  the  symptoms  will  give  us  a  some- 
what different  description.  Under  those  circumstances 
it  is  well  to  be  cautious,  I  think,  as  to  operation. 

People  who  cannot  get  operated  upon  at  once  for 
acute  appendicitis  may  get  through  by  starving  them- 
selves in  the  attack.  Other  than  operation  the  essen- 
tials of  treatment  are  starvation  and  rest  in  bed. 
Starvation  is  necessary  because  every  mouthful  of 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

food  taken  into  the  stomach  sends  a  wave  of  contrac- 
tion down  the  intestine  as  far  as  the  appendix  and  be- 
yond it.  That  wave  of  contraction  stirs  things  up  and 
prevents  the  quieting  down  of  the  inflammatory  pro- 
cess. For  the  same  reason  a  purgative,  which  is  often 
given,  is  the  very  worst  possible  treatment.  Many 
people  and  even  some  physicians  say  that  it  is  a  good 
plan  to  clean  ourselves  out  when  we  have  a  stomach- 
ache. If  the  thing  we  are  afflicted  with  happens  to  be 
appendicitis,  we  could  not  do  anything  worse.  A  tri- 
fling case  is  often  made  serious  or  even  fatal  by  ill- 
timed  purgation. 

As  a  rule  surgeons  do  not  want  to  operate  at  the 
height  of  the  attack.  The  course  of  the  experienced 
surgeon  is  something  like  this:  He  has  seen  a  patient, 
say,  at  eight  o'clock  in  the  morning,  has  recorded  the 
pulse,  temperature,  blood,  and  noted  the  condition  of 
the  abdomen ;  he  sees  him  again  at  ten  o'clock;  if  things 
are  getting  better,  he  waits  —  if  worse,  he  operates.  So 
he  follows  the  patient  along  at  two- hour  periods,  and 
as  long  as  things  are  going  well  he  waits,  hoping  to 
operate  between  attacks.  If  the  patient  gets  worse,  he 
may  have  to  operate  at  once.  The  patient  should  be 
where  a  skilful  physician  can  get  his  hand  on  to  the 
abdomen  and  his  eye  to  the  microscope  within  two 
hours.  Under  these  conditions  one  runs,  as  a  rule,  no 
risk  in  waiting  while  the  attack  is  subsiding. 

In  examining  the  blood  in  appendicitis,  or  in  any 
fever,  the  doctor  is  looking  for  leucocytosis.  Leucocy- 

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DISEASES  OF  THE   INTESTINE 

tosis  means  the  mobilization  of  the  army  that  fights  on 
our  side  against  the  germs.  We  can  rarely  find  the 
germ  in  the  blood,  but  we  can  find  the  army  which 
begins  to  gather  in  all  parts  of  the  body  as  soon  as  there 
is  trouble  in  the  appendix.  Just  as  if  we  saw  soldiers  on 
the  roads  we  might  know  there  was  a  call  for  them  some- 
where, so  if  we  find  the  number  of  leucocytes  in  the 
blood  vessels  increased,  we  know  that  they  must  be 
gathering  to  meet  some  invader.  If  we  know  also  that 
there  is  a  local  tenderness  in  the  right  iliac  fossa,  we 
strongly  suspect  that  the  invader  is  there.  We  count 
the  leucocytes  and  count  them  hour  by  hour  to  see  if 
the  count  rises  above  normal.  If  they  have  been  nu- 
merous and  grow  less,  it  means  either  that  the  patient 
is  getting  much  worse  or  that  he  is  getting  better;  we 
cannot  tell  much  about  that  from  the  count  alone. 

Inflammation  of  the  intestine  is  called  colitis  when  it 
affects  the  colon,  or  the  lower  four  or  five  feet  of  the 
intestine,  and  enteritis  when  it  affects  the  smaller  in- 
testine above.  The  disease  produces  diarrhea  in  a  great 
majority  of  cases.  It  may  be  very  unimportant  or 
very  important,  according  to  what  other  symptoms  go 
with  it.  Diarrhea  is  sometimes  the  result  merely  of 
nervousness;  more  often  it  is  the  result  of  some  infec- 
tion or  of  some  food  which  has  irritated  the  intestine. 
Diarrhea  is  the  beginning  of  many  acute  diseases  like 
typhoid  fever;  it  is  the  final  stage  of  a  good  many 
chronic  diseases  like  cirrhosis  or  Bright's.  It  is  very 
apt  to  make  people  faint.  It  is  important  to  know  that 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

without  being  at  all  seriously  ill,  any  one  whose  bowels 
are  loose  is  likely  to  feel  faint  or  actually  to  faint. 
With  old  people  this  may  mean  a  fall  and  serious  in- 
jury from  the  fall. 

The  appearance  of  blood  in  the  discharges  is  not  nec- 
essarily serious.  In  children  it  is  quite  common.  The 
appearance  of  blood  in  movements  previously  free 
from  it  may  lead  the  doctor  to  call  it  " dysentery"  in- 
stead of  "diarrhea,"  although  nothing  has  changed  ex- 
cept the  name.  The  appearance  of  mucus  is  also  of 
no  especial  importance,  and  does  not  mean  any  severe 
inflammation.  The  gravity  of  the  trouble  is  judged  by 
its  duration,  by  the  patient's  strength,  and  by  the  ex- 
amination of  the  stools.  The  serious  cases  are  usually 
those  which  last  a  long  time.  The  intestine  can  stand 
a  great  deal  of  inflammation,  and  the  body  can  bear  a 
great  deal  of  this  trouble,  but  after  months  and  years 
it  begins  to  be  a  strain. 

Outside  the  tropics  chronic  dysentery  (chronic  diar- 
rhea, chronic  enteritis)  is  rare,  but  most  of  us  have 
known  veterans  of  the  Civil  War  who  got  amoebic 
dysentery  in  the  Civil  War  and  have  never  got  alto- 
gether rid  of  it  since. 

41  Simple  diarrhea  "  or  acute  colitis  of  adults  gets  well 
as  a  rule  in  a  week  or  ten  days.  The  important  reme- 
dies are  rest  and  warmth  anct  starvation.  Such  a  .per- 
son should  stay  by  the  fire,  move  as  little  as  possible, 
and  eat  as  little  as  possible  for  a  day  or  two.  One  can- 
not keep  that  up  indefinitely,  of  course.  It  makes  little 

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DISEASES  OF  THE   INTESTINE 

difference  what  we  eat  in  cases  of  acute  diarrhea. 
There  is  a  very  widespread  superstition  that  boiled 
milk  has  a  particular  efficacy  in  diarrhea,  but  it  has 
not.  The  main  thing  is  to  put  as  little  of  anything  in 
the  stomach  as  possible,  and,  because  boiled  milk  is  so 
boresome  a  food,  we  generally  soon  get  sick  of  it  and 
so  put  very  little  in.  We  should  not  eat  any  food  con- 
taining a  large  amount  of  cellulose  and  a  large,  irritat- 
ing residue,  e.g.  corned  beef  and  cabbage.  Otherwise 
there  is  no  choice  between  carbohydrates,  proteids, 
and  fats.  The  small  quantity  is  the  main  thing.  Foods 
that  are  cold  sometimes  act  as  cold  externally  does,  to 
stimulate  the  intestine,  and  for  that  reason  we  gener- 
ally try  to  give  food  warm  as  well  as  to  protect  the 
body  from  cold. 

If  the  patient  is  seen  within  the  first  twenty- four 
hours  the  doctor  often  helps  by  giving  a  purge.  There 
is  irritating  material  in  the  bowel  and  if  swept  out  it  gets 
better  more  quickly.  In  children  we  often  give  castor  oil 
or  calomel  in  small  doses,  and  often  the  diarrhea  stops 
as  a  result  of  what  seems  likely  to  increase  it,  a  purge. 

I  remember  once  talking  with  a  physician  who  was 
telling  me  how  he  had  lost  practice  and  money  in  the 
treatment  of  babies. 

He  said,  "  I  do  not  see  one  baby  for  every  ten  I  used 
to  see,  now." 

I  said,  "  Well,  why  is  that? " 

"It  is  like  this,"  he  said.  "A  lady  called  me  up  the 
other  day,  and  told  me  her  baby  had  a  little  trouble  in 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

his  bowels.  *I  have  stopped  all  food,1  said  she,  'given 
water  in  plenty,  and  one  tenth  grain  of  calomel  every 
hour  for  five  doses.  Is  there  anything  else  I  ought  to  do 
for  the  baby?'  I  said  no,  not  just  now.  'Well,'  she 
said,  'if  the  baby  is  not  better  soon  I  shall  want  you  to 
come  and  see  him/  But  the  baby  was  better,  and  I  was 
never  called.  I  had  taught  the  mother  all  she  knew  and 
most  that  I  knew  about  babies." 

We  ought,  I  think,  all  of  us,  to  know  as  much  as  that 
mother  did.  She  stopped  all  food;  she  gave  the  baby 
all  the  water  he  would  take,  to  make  up  for  the  drain 
of  liquid  from  his  bowels ;  she  gave  the  baby  one  tenth 
grain  of  calomel  every  hour  for  five  hours.  A  fiftieth 
or  even  a  hundredth  grain  of  calomel  probably  would 
have  done  as  well. 

Castor  oil  is  sometimes  useful  as  a  purge,  within  the 
first  twenty-four  hours,  to  clean  up  the  irritating  ma- 
terial. If  the  trouble  has  been  going  on  longer  than 
that,  it  is  well  not  to  give  it.  After  a  diarrhea  it  is  per- 
fectly safe  to  leave  the  bowels  without  any  movement 
for  two  or  three  days,  because  it  takes  some  time  for  the 
bowels  to  fill  up  again  sufficiently  to  need  any  empty- 
ing. 

"Dysentery"  is  the  term  generally  used  in  cases 
where  there  is  blood,  but  there  is  no  special  reason  for 
confining  it  to  that  usage.  Infectious  diarrhea  does  not 
always  have  blood.  We  can  have  blood  in  mild  or  in 
severe  cases;  it  is  no  criterion. 

In  diarrhea  from  nervousness  we  should  try  to  re- 

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DISEASES  OF  THE   INTESTINE 

move  the  cause  of  the  nervousness.  I  have  treated  a 
number  of  these  cases  without  any  reference  to  the 
bowels  at  all,  by  trying  to  straighten  out  the  person's 
mind.  That  particular  type  of  person  often  has  to  be 
told  not  to  allow  the  bowels  to  move.  People  get  in  the 
habit  of  thinking  that  when  the  bowels  want  to  move 
they  always  must.  Ordinarily  that  is  true,  but  diar- 
rhea may  be  a  habit,  and  one  which  can  be  broken  up 
only  by  forbidding  the  bowels  to  move  more  than  once 
a  day. 

Almost  nothing  can  be  done  for  the  diarrhea  which 
accompanies  tuberculosis,  except  to  treat  the  tuber- 
culosis. It  is  very  important  not  to  think  that  it  is 
hopeless.  It  often  gets  well  along  with  the  recovery  of 
the  patient's  lungs. 

It  is  very  hard  to  estimate  the  chances  of  recovery 
from  tuberculosis  of  the  intestine,  because  the  diagnosis 
is  almost  impossible;  I  should  suppose  that  they  were 
poor.  But  for  a  person  who  has  tuberculosis  of  the  lungs 
plus  a  chronic  diarrhea,  supposed  to  be  tuberculous, 
the  chances  are  pretty  good.  If  it  is  genuinely  tuber- 
culosis of  the  bowel  itself,  the  chances  are  probably 
poor,  but  it  is  almost  impossible  to  make  that  diagnosis. 
Tubercle  bacilli  in  the  stools  mean  nothing  as  evidence 
of  internal  tuberculosis,  because  they  are  often  merely 
sputum  swallowed,  and  passed  along. 

Intestinal  obstruction  is  a  frequently  fatal,  but  luckily 
rare,  disease.  A  great  majority  of  all  cases  die.  When 
the  intestine  is  obstructed,  behind  the  point  of  ob- 

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struction  poisons  form  with  extraordinary  rapidity  and 
the  patient  dies  of  self-poisoning.  Why  this  is  so  we 
do  not  know,  and  why  it  does  not  happen  in  consti- 
pation we  do  not  know.  When  the  bowels  are  totally 
obstructed  for  more  than  forty-eight  hours,  the  chances 
of  life  are  poor. 

Obstruction  occurs  in  general  from  two  great  groups 
of  causes.  It  occurs  in  young  or  moderately  young 
people  as  a  result  of  bands  or  scars  in  and  around  the 
intestines  as  a  result  of  previous  peritonitis  or  previous 
operation.  All  inflammation  leaves  scars,  and  it  can- 
not be  too  often  said  that  every  operation  also  leaves 
behind  it  scars  and  adhesions,  so  that  an  operation 
done  for  the  cure  of  adhesions  generally  leaves  more 
than  it  finds.  Adhesions  mean  bands  of  tissue,  tough 
fibres,  which  ordinarily  do  no  harm,  but  if  the  intes- 
tine happens  to  get  caught  round  one  of  those  bands, 
''strangulated, "  as  we  say,  only  a  very  rapid  and  skil- 
ful operation  can  save  life. 

Of  this  same  type  is  strangulated  hernia.  Hernia  is 
the  protrusion  of  a  piece  of  bowel  under  the  skin 
through  a  weak  place  in  the  abdominal  muscles.  In  the 
groin  or  in  the  scar  of  previous  operations  on  the  ab- 
dominal wall  there  is  often  a  weak  place.  The  constant 
pressure  of  the  intestine  outward  in  the  course  of  cough- 
ing or  muscular  exertion  weakens  and  stretches  this 
place  until  finally  a  bulge  occurs  and  we  have  "rup- 
ture "  or  hernia.  It  is  nothing  but  a  bother  except  for 
the  chance  of  its  becoming  strangulated,  but  this  bit  of 

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DISEASES  OF  THE   INTESTINE 

bowel  which  protrudes  through  the  abdominal  wall, 
until  it  has  nothing  but  the  skin  and  subcutaneous  fat 
over  it,  may  at  any  time  get  caught,  bent  upon  itself, 
and  narrowed  so  that  its  contents  cannot  pass  on.  Then 
obstruction  or  strangulation  of  the  gut  occurs.  We  or- 
dinarily hold  up  a  hernia  with  a  truss ;  that  is,  we  have 
something  that  presses  up  against  the  weak  place  and 
holds  the  hernia  in  place.  When  strangulation  occurs 
there  must  be  a  rapid,  skilful  operation  or  death  will 
follow.  The  operation  means  cutting  the  band  and 
straightening  out  the  kinked  intestine. 

To  laymen  it  seems  to  me  a  practical  point  that 
all  unnecessary  operations  should  be  avoided  for  this 
among  other  reasons:  that  all  operations  on  the  perito- 
neum leave  scars  there,  and  those  scars  are  always  liable 
to  produce  fatal  intestinal  obstruction.  Another  point 
is  that  hernia,  rupture,  is  never  a  wholly  unimportant 
matter  because  of  the  danger  of  strangulation,  and  as  a 
result  of  that  danger  we  nowadays  advise  every  young, 
strong  person  who  has  a  hernia  to  have  it  cured,  to 
have  the  weak  place  sewn  up.  It  is  an  operation  of  al- 
most no  danger  in  skilful  hands,  and  in  young,  strong 
people.  In  old,  weakened  people,  or  with  an  unskilful 
surgeon,  it  is  dangerous.  Those  who  examine  candi- 
dates for  military  service  always  refuse  men  with  hernia. 

The  other  common  cause  of  intestinal  obstruction  is 
cancer ',  and  when  obstruction  occurs  in  elderly  people 
the  chances  are  very  great  that  it  is  due  to  cancer  of 
the  intestine.  This  is  a  slow  disease,  quite  unlike  that 

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which  I  have  just  described,  coming  on  gradually  with 
increasing  constipation  in  elderly  people,  with  plenty  of 
time  to  consider  what  is  to  be  done,  but  unfortunately 
with  very  little  to  be  done.  We  can  almost  never  re- 
move the  whole  of  an  intestinal  cancer;  usually  all  we 
can  do  is  to  give  the  person  relief  for  a  little  while, 
months  or  years,  by  making  another  opening  in  the 
bowel  above  the  obstruction,  so  that  the  bowel's  con- 
tents may  be  discharged  for  the  rest  of  the  person's  life 
through  the  abdominal  wall.  It  will  save  life  and  pro- 
long it,  but  at  a  pretty  high  price  of  discomfort. 

Of  course  it  is  possible  to  cut  out  the  particular 
piece  of  the  intestine  affected,  but  when  cancer  is  in 
the  bowel  it  is  almost  always  in  some  other  place 
whether  we  find  it  or  not.  It  is  usually  spread  much 
more  widely  than  appears,  and  hence  we  cannot  get 
it  all  out. 

After  an  operation,  the  length  of  time  before  exercise 
should  be  taken  depends  on  the  length  and  width  of  the 
scar.  Many  cases  of  appendicitis  have  a  line-scar  not 
more  than  an  inch  long,  and  if  everything  is  done  to  pre- 
vent damage  to  the  abdominal  wall  it  heals  within  two 
or  three  weeks.  A  scar  a  foot  long  is  very  much  harder 
to  make  sure  of  strengthening,  and  the  person  can 
hardly  ever  be  safe  from  hernia.  If  the  scar  is  parallel 
to  the  muscular  fibres  and  not  across  them,  there  is  a 
very  much  better  chance  of  a  firm,  unyielding  result, 
avoiding  a  hernia  through  the  scar. 


CHAPTER  VII 

DISEASES  OF   THE   KIDNEY  AND   BLADDER 

Diseases  of  the  Kidney 

BRIGHT'S  DISEASE  is  the  most  important  disease  of  the 
kidney  from  the  point  of  view  of  laymen  and  social  work- 
ers. Bright's  disease  comes  about  chiefly  because  of  the 
wear  and  tear  upon  the  kidney  in  the  process  of  getting 
poisons  and  bacteria  out  of  the  body.  The  kidney  is  one 
of  the  three  or  four  great  channels  by  which  poisons 
are  got  out  of  the  body,  whether  those  poisons  are  or- 
ganized —  that  is,  bacteria  —  or  unorganized  —  like  ar- 
senic and  mercury.  The  kidney  suffers  in  the  wear  and 
tear,  and  we  get  latent,  usually  chronic  inflammations, 
which  finally  come  to  the  doctor  as  Bright's  disease. 
We  have  acute  and  chronic  —  that  is,  short  and  long  — 
types  of  Bright's  disease,  the  acute  type  much  rarer 
and  much  less  serious. 

Acute  Bright's  disease  is  seen  most  often  in  children, 
especially  in  connection  with  scarlet  fever,  when  the 
germs  of  scarlet  fever  are  on  their  way  through  the 
kidney.  Hence  a  post-scarlatinal  nephritis  is  one  of 
the  things  we  fear  most  in  scarlet  fever.  Any  other  of 
the  infectious  diseases  that  children  have  may  produce 
nephritis,  but  very  few  of  them  do.  Next  to  scarlet 
fever,  diphtheria  is  the  most  dangerous,  and  next  to 

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that,  the  streptococcus  disease  which  starts  in  the 
throat,  to  which  I  have  referred  so  often  as  a  cause  of 
joint  trouble  and  of  heart  trouble  and  of  wound-infec- 
tions. Streptococcus  sore  throat,  or  streptococcus  dis- 
ease starting  elsewhere  in  the  body,  may,  in  children  as 
well  as  in  adults,  hurt  the  kidney  seriously.  One  of  the 
things  that  we  have  just  begun  to  realize  is  that  what 
we  call  "a  simple  sore  throat,"  "a  little  touch  of  ton- 
sillitis," may  have  very  serious  effects  upon  the  kidney. 
One  of  my  colleagues  had  such  a  sore  throat  with  a  re- 
sulting nephritis  which  will  never  get  well,  and  which 
will  end  his  life  within  a  year  or  two. 

Poisons  such  as  mercury  and  lead  are  also  causes  of 
Bright's  disease.  Mercury  taken  with  suicidal  intent 
in  countries  such  as  Germany,  where  less  painful  poi- 
sons are  hard  to  get,  causes  many  deaths  from  acute 
Bright's  disease.  The  other  day  in  the  out-patient 
department  of  the  Massachusetts  General  Hospital  we 
had  a  very  pitiful  case  of  a  negress  who  had  pediculosis 
(extra  inhabitants  in  the  hair)  and  for  the  relief  of  that 
had  rubbed  in  a  mercury  ointment.  She  had  bought 
only  a  small  box,  containing  about  a  teaspoonful  ap- 
parently, but  she  had  got  a  tremendously  severe  mer- 
curial poisoning  as  a  result.  One  effect  was  acute 
Bright's  disease. 

Corrosive  sublimate  used  as  an  antiseptic  does  not 
generally  do  any  harm,  but  occasionally,  in  women 
after  child-birth,  its  use  as  a  douche  within  the  womb 
results  in  the  death  of  the  women  through  the  entry  of 

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DISEASES  OF  THE   KIDNEY 

the  mercury  into  the  uterus,  its  absorption  there,  and 
subsequent  poisoning  of  the  kidney. 

Bright 's  disease  does  not  result  from  getting  cold,  or 
from  eating  anything  in  particular,  or  from  any  of  the 
causes  that  people  are  apt  to  assign.  It  cannot  come 
from  any  strain  of  the  back  or  from  any  blow  or  any 
local  cause.  So  far  as  we  know  it  comes  only  from  the 
two  classes  of  causes  that  I  have  spoken  of  —  germs 
and  poisons. 

Acute  Bright's  disease  gets  well  or  kills  within  a  few 
weeks.  Chronic  Bright's  disease  never  gets  well,  but 
may  persist  with  very  fair  health  for  ten  or  even  twenty 
to  thirty  years.  Like  acute  Bright's  disease  it  shows 
itself  by  swelling  of  the  whole  body.  I  have  seen  a 
child  puffed  up  till  he  looked  like  a  pin-cushion,  — 
face,  hands,  and  feet  tremendously  swollen,  —  and 
yet  entire  recovery  follow.  That  swelling  is  called 
dropsy,  and  the  kidney  is  the  other  great  cause,  aside 
from  heart  disease,  of  dropsy.  Kidney  disease  in  the 
acute  form,  without  disease  of  the  heart,  may  cause 
dropsy,  but  the  dropsy  usually  differs  from  heart 
dropsy  in  involving  thesface  first,  whereas  heart  dropsy 
involves  the  feet  first.  Along  with  dropsy  come  changes 
in  the  urine,  some  of  which  are  easily  seen,  such  as  the 
bloody  color  due  to  blood  in  the  urine  (some  cases  only). 
Others  are  microscopic,  although  none  of  them  are 
difficult  to  recognize.  i 

Bright's  disease  also  shows  itself  in  a  poisoning  of 
the  nervous  system.  I  have  said  before  that  the  func- 

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tion  of  the  kidney  is  to  take  poisons  out  of  the  body. 
When  it  is  damaged,  poisons  accumulate  in  the  system 
and  produce  a  self-poisoning  which  we  call  uremia. 
There  are  two  roots  in  this  word,  the  ur  which  means 
urine,  and  the  emia  which  means  blood.  Thus  the 
word  means  urine  in  the  blood,  which  is  not  quite  true. 
But  some  substances  from  the  urine  do  get  into  the 
blood  as  a  cause  of  uremia,  so  that  it  is  a  perfectly 
proper  term.  Some  of  those  poisons  affect  the  brain. 
As  a  result  we  have,  first,  headache ;  second,  vomiting, 
of  the  brain  type  —  i.e.,  a  vomiting  which  has  nothing 
to  do  with  food.  The  ordinary  stomach  kind  of  vomiting 
comes  after  food  and  as  a  result  of  food ;  the  t>rain  type 
comes  just  the  same  whether  there  isTany  food  in  the 
stomach  or  not.  Headache,  vomiting,  then  convulsion 
(fit),  and  coma  (unconsciousness)  — this  is  the  group 
of  symptoms  produced  by  acute  uremia,  and  in  spite 
of  all  those  symptoms,  and  more  too,  a  person  may  get 
wholly  well  from  acute  Bright's  disease.  We  never  de- 
spair so  long  as  we  are  sure  that  the  disease  is  acute, 
not  chronic. 

There  are  two  other  striking  symptoms :  one  is  blind- 
ness, —  sudden,  complete  blindness,  —  due  to  the  ef- 
fect of  the  poison  on  the  nerves  at  the  back  of  the 
head,  the  occipital  lobe  of  the  brain  where  sight  is.  One 
of  the  strange  things  about  sight  is  that  we  see  with  the 
back  of  the  brain  and  not  with  our  eyes  alone.  In 
uremia  the  poisoning  of  the  brain  may  involve  sudden 
loss  of  sight  and  also  delirium  or  temporary  insanity. 

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DISEASES  OF  THE  KIDNEY 

I  remember  a  little  boy  brought  into  our  wards,  abso- 
lutely blind  and  in  violent  delirium.  He  had  convul- 
sions, was  unconscious,  and  had  a  urine  full  of  blood. 
He  had  also  a  peeling  round  his  finger  ends,  due  to  a 
scarlet  fever  which  had  not  been  noticed.  That  little 
boy  got  absolutely  well  and  stayed  well. 

The  treatment  of  acute  Bright's  disease,  with  or 
without  acute  uremia,  is  in  the  first  place  the  removal 
from  the  kidney  of  all  possible  strain.  There  is  strain 
upon  the  kidney  in  the  effort  to  excrete  the  products  of 
digestion.  To  give  it  nothing  to  do,  we  starve  the  per- 
son, —  and  for  an  acute  illness  which  is  only  going  to 
last  a  few  days  it  is  safe  and  right  to  starve  him.  This 
rests  the  kidney,  allowing  it  to  heal.  We  give  water 
and  nothing  else  in  the  earliest  days  of  acute  Bright's 
disease.  Later  we  give  the  next  mildest  of  all  foods ;  that 
is,  milk.  No  medicine  helps  the  kidney  at  all  to  get  rid 
of  this  inflammation,  but  we  do  something  to  rest  the 
kidney  and  to  relieve  dropsy.  Dropsy  is  removed  by 
purgation,  by  drawing  water  out  of  the  tissues  into  the 
bowel  and  thence  out  of  the  body.  It  is  relieved  also 
by  sweating.  Patients  with  Bright's  disease  are  given 
a  hot-air  bath  or  a  hot  pack,  with  the  idea  of  drawing 
water  out  through  the  skin.  We  put  the  patient  in  bed 
with  rubber  sheeting  around  him,  so  that  no  heat  can 
pass  out,  and  then  put  the  upper  end  of  a  piece  of  right- 
angled  stovepipe  up  under  the  sheeting,  and  a  lamp 
under  the  lower  end  of  that  stovepipe.  The  heat  goes 
up  through  the  pipe  and  under  the  bedclothes,  where 

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it  is  held  in  by  tucking  blankets  tightly  round  the  pa- 
tient's head  and  feet.  As  a  rule  we  cannot  get  it  too 
hot,  not  above  120°,  the  temperature  we  like  to  pro- 
duce. We  leave  the  patient  there  half  an  hour  or  so, 
provided  he  perspires  freely.  The  stovepipe  must  be 
sheathed  in  asbestos;  else  we  may  set  the  bed  afire. 

In  relation  to  social  work,  the  most  important  thing 
is  to  know  the  danger  of  acute  B right's  disease  after 
the  acute  infectious  diseases,  especially  after  scarlet 
fever,  and  as  a  result  of  mercury  or  arsenic  poisoning. 
It  also  occurs  in  pregnancy,  is  one  of  the  dangers  of 
every  pregnancy,  and  that  also  has  to  be  taken  into 
reckoning. 

Chronic  Bright' s  disease,  of  which  there  are  several 
types  which  laymen  do  not  need  to  distinguish,  lasts 
for  many  years.  Those  who  have  it  often  die  of  some- 
thing else  rather  than  of  that  disease.  Most  of  the 
symptoms  of  chronic  Bright's  disease  are  not  on  the 
part  of  the  kidney,  but  on  the  part  of  the  heart,  for 
one  of  the  most  important  effects  of  chronic  Bright's 
disease  is  to  raise  blood  pressure  and  so  to  weaken 
the  heart.  I  referred  to  high  pressure  in  connection 
with  arteriosclerosis.  There  are  only  three  important 
causes  for  high  blood  pressure,  arteriosclerosis,  chronic 
Bright's  disease,  and  eclampsia,  actual  or  impending. 

*- 

High  blood  pressure  produces  first  an  over-strong 
heart,  the  heart  compensating  as  it  does  so  wonder- 
fully, and  'then  finally  weakening  and  failure. 

It  is  the  heart,  then,  that  shows  most  of  the  symr> 
•          1 66 


DISEASES  OF  THE   KIDNEY 

toms  of  chronic  B right's  disease.  Patients  may  come  to 
a  doctor  for  nausea  or  headache,  but  generally  for  short 
breath  and  swelling  of  the  feet  and  the  other  familiar 
symptoms  of  heart  trouble.  All  the  manifestations  of 
uremia  which  I  mentioned  under  acute  B  right's,  may 
also  come  in  chronic  B  right's,  although  they  are  more 
rare  in  the  chronic  types.  They  may  come  suddenly, 
when  a  person  has  been  in  tolerable  health  and  not 
aware  of  any  poisons  in  the  system.  We  must  realize 
that  a  chronic  disease  like  Bright's  may  exist  quite  un- 
known for  years  and  then  suddenly  "wake  up"  and 
produce  symptoms,  so  that  the  patient  is  apt  to  say 
that  he  knows  just  what  brought  it  on  him  yesterday. 
Yet  the  doctor,  finding 'his  blood  pressure  high  and  his 
heart  twice  its  proper  size,  knows  that  the  disease  has 
been  going  on  for  some  years,  because  it  takes  years  to 
produce  such  enlargement  of  the  heart.  That  is  very 
important,  especially  in  regard  to  industrial  compensa- 
tion. Only  recently  I  saw  what  I  believe  to  be  the 
greatest  injustice  in  the  awarding  a  man  several  thou- 
sand dollars,  the  full  value  of  a  man's  life  as  it  is  taken 
to  be,  because  his  heart  had  suddenly  failed  while  he 
was  at  work.  His  blood  pressure  showed  that  his  heart 
had  been  diseased  for  years.  But  he  had  not  known 
that  he  was  sjck,  and  therefore  his  work  was  blamed  as 
the  cause  of  his  trouble,  and  the  State  had  to  pay  sev- 
eral thousand  dollars,  wholly  unjustly,  I  think.  That 
sort  of  error  is  going  to  be  corrected,  I  believe,  by  the 
physical  examination  of  employees.  Employers  must 

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protect  themselves  by  having  the  blood  pressure  meas- 
ured in  all  employees  over  forty  years  old.  In  that  way 
they  will  weed  out  these  men  who  are  liable  at  any 
moment  to  have  the  heart  give  out  whether  they  are 
at  rest  or  at  work,  and  to  bring  this  big  penalty  down 
upon  the  employer  or  upon  the  insurance  company. 

Oftentimes  in  the  chronic  Bright's  disease,  blindness 
or  partial  blindness  is  the  first  complaint.  A  good  many 
of  these  patients  go  to  an  eye  specialist  complaining 
wholly  of  poor  sight,  without  any  knowledge  that  any 
other  organ  is  diseased.  The  doctor  finds  in  the  retina 
hemorrhage  and  inflammation  of  the  type  that  Bright's 
disease  can  produce  in  the  eye,  and  knowing  that  he 
can  do  nothing,  refers  the  patient  to  a  general  practi- 
tioner to  see  if  anything  can  be  done  to  help  the  disease. 
The  blindness  may  get  a  little  better,  but  patients 
never  get  back  their  full  sight,  and  as  a  rule  they  get 
very  little. 

The  treatment  of  chronic  Bright's  disease  differs 
from  that  of  acute  in  that  we  cannot  starve  the  patient 
or  spare  the  kidney  for  months  and  years  as  we  can  for  a 
few  days.  So  we  can  only  make  slight  changes  in  his 
diet,  the  essential  of  which  is  to  cut  down  on  meat  and 
meat  soups.  Next  to  that  the  most  important  thing  is 
to  leave  out  as  much  as  possible  of  the  salt  which  he 
adds  to  his  meals.  Salt  has  the  property  of  attracting 
water  —  as  we  all  know  from  our  observation  of  table- 
salt  —  outside  the  body  and  inside  the  body.  The  salt 
that  we  take  with  our  meals  tends  to  hold  water  in  the 

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DISEASES  OF  THE   KIDNEY 

body,  and  if  we  have  a  disease  like  Bright's,  which  al- 
ready tends  to  produce  dropsy,  all  the  salt  we  take 
into  our  bodies  tends  to  increase  the  danger  of  dropsy. 
We  caution  people  not  to  cut  salt  out  altogether,  but 
to  add  as  little  as  possible  and  yet  have  some  appetite 
for  their  meals.  Medicines  here,  as  in  acute  Bright's 
disease,  have  no  effect  except  in  so  far  as  they  help  to 
relieve  dropsy  or  to  stimulate  the  heart. 

One  of  the  common  complications  of  chronic  Bright's 
disease  is  apoplexy  or  cerebral  hemorrhage.  I  have  said 
that  the  blood  pressure  is  raised  in  chronic  Bright's. 
The  results  of  high  blood  pressure  are  shown  in  many 
ways,  but  nowhere  so  seriously  as  in  the  brain,  where 
the  breaking  of  a  small  artery  (which  would  do  no 
harm  anywhere  else)  may  be  fatal.  Apoplexy,  of  which 
the  popular  name  is  "shock,"  means  that  an  artery  in 
the  brain  suddenly  becomes  useless,  or  breaks.  It  may 
become  useless  by  being  plugged.  In  that  case  it  does 
not  supply  the  brain  with  blood,  and  the  trouble  is 
just  as  great  as  if  it  should  break  and  let  blood  out  into 
the  brain.  Apoplexy  is  the  death  that  we  should  all  of 
us  pray  to  have  come  to  us.  It  is  the  most  painless,  the 
quickest,  and  it  rarely  comes  to  any  one  who  is  not 
hopelessly  diseased,  either  by  this  trouble  or  by  same 
other.  The  symptoms  are  sudden  unconsciousness 
and  paralysis,  more  or  less  widespread,  usually  of  half 
the  body  — ' '  hemiplegia. ' '  Any  one  who  comes  to  an 

1  Notice  the  stems:  hemi,  half,  and  plegia,  paralysis.  We  see  that 
hemi  in  other  things,  as  hemi-  anesthesia,  numbness  of  half  the  body; 

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out-patient  department  must  see  a  good  many  of  the 
old  hemiplegics,  scuffing  one  toe  and  holding  one  hand 
turned  in  across  the  body.  They  often  live  for  years 
after  their  first  attack;  that  is,  although,  as  I  have  said, 
a  severe  apoplexy  often  causes  sudden  and  painless 
death,  it  may  be  so  slight  that  the  person  will  live  on 
for  many  years  before  he  has  another  break  in  his  cere- 
bral arteries. 

I  think  it  always  results  in  some  mental  impairment. 
Sometimes  this  is  very  slight,  but  I  think  there  is  al- 
most always  some  mental  change,  and  there  is  often 
change  in  speech,  aphasia.1  Aphasia  means  that  al- 
though the  person  knows  what  he  wants  to  say,  he  can- 
not say  it  even  though  his  tongue  is  not  paralyzed. 
Ordinarily  he  can  write  what  he  wants  to  say,  but  can- 
not speak  it. 

I  remember  when  I  was  a  boy  hearing  a  course  of 
emergency  lectures  in  which  we  were  told  the  proper 
treatment  for  apoplexy  and  for  epilepsy.  In  one  of 
them,  we  were  told,  be  sure  to  have  the  patient  lie 
down,  and  in  the  other  sit  up  —  I  soon  forgot  which 
was  which,  and  I  was  very  much  worried  then ;  but  la- 
ter, when  I  came  to  study  medicine,  I  was  greatly  com- 
forted because  I  came  to  know  that  it  does  not  make 

hemi-  chorea,  chorea  affecting  only  one  half  the  body.  Para  plegia  means 
paralysis  of  both  legs;  mono  plegia,  of  one  leg.  Knowing  these  stems  one 
can  often  recognize  the  meaning  of  a  word  never  seen  before. 

1  In  the  word  aphasia,  a  means  that  you  cross  out  the  meaning  of 
whatever  word  comes  after  it,  and  phasia  means  speech.  Thus,  a-netnia 
means  literally  no  blood;  a-nuria,  no  urine. 

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DISEASES  OF  THE   KIDNEY 

the  slightest  difference  what  we  do  in  such  cases.  When 
a  person  has  apoplexy  he  is  going  to  get  well  or  die  ac- 
cording to  the  nature  of  the  disease,  and  what  we  do  or 
the  physician  does  at  the  time  of  the  attack  makes  no 
important  difference.  The  trouble  is  out  of  reach,  in- 
side the  brain.  In  a  way  it  is  very  hard  to  sit  still  and 
do  nothing  about  it.  We  want  to  fly  around  and  be 
busy,  but  in  truth  there  is  absolutely  nothing  to  do. 
In  future  this  may  not  be  so,  but  nobody  has  as  yet 
discovered  anything  to  check  or  cure  apoplexy  or  epi- 
lepsy. The  layman  may  well  remember  that  in  the 
acute  attack  of  either  disease  he  is  just  as  good  as  the 
most  skilful  physician  in  the  world,  because  neither 
can  do  anything  whatsoever. 

I  do  not  think  anybody  would  be  likely  to  mistake 
sunstroke  for  apoplexy.  What  we  do  in  sunstroke 
makes  all  the  difference  between  life  and  death.  But 
epilepsy  has  exactly  the  same  treatment  as  apoplexy; 
namely,  no  treatment  at  all.  The  patient  cannot  choke 
in  either  case.  If  the  tongue  slips  back  into  the  throat 
he  soon  rouses  himself  enough  to  cough  it  out.  The 
difficulty  in  breathing  is  due  to  the  involvement  of  the 
breathing  centre.  We  breathe  by  reason  of  a  little  nerve 
centre  of  the  lower  part  of  the  brain,  whence  a  rhythmic 
impulse  is  sent  out  about  twenty  times  a  minute.  This 
impulse  causes  us  to  breathe.  In  brain  hemorrhages 
that  centre  is  sometimes  damaged  and  hence  breath- 
ing may  be  very  difficult.  The  snoring  sound  merely 
means  that  the  patient  is  deeply  unconscious.  Any 

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other  disease  which  gave  deep  unconsciousness  would 
produce  the  same  kind  of  snoring. 

High  blood  pressure  is  discovered  by  a  very  simple 
test.  I  think  any  social  worker  would  be  the  better 
for  knowing  it  and  could  learn  it  in  fifteen  minutes. 
For  though  one  of  the  simplest,  it  is  the  most  important 
of  all  medical  tests. 

Chronic  Bright's  disease  affects  the  mind  in  a  con- 
siderable proportion  of  cases,  because  the  self-poison- 
ing uremia  that  I  spoke  of  as  affecting  the  brain, 
through  headache,  vomiting,  convulsions,  and  coma, 
also  affects  the  other  functions  of  the  brain.  There 
are  many  insanities  and  mental  disturbances  resulting 
from  chronic  Bright's  disease,  most  of  them,  very  easily 
suspected  if  on  measuring  the  blood  pressure  we  find  it 
high. 

Floating  kidney.  The  chief  point  to  remember  is 
that  in  the  vast  majority  of  cases  it  is  not  a  disease.  It 
is  a  privilege  of  about  half  the  female  sex,  and  almost 
the  only  harm  that  comes  from  it  is  through  doctors  or 
friends  who  talk  about  it.  It  is  quite  a  serious  thing  to 
be  informed  that  one  has  a  floating  kidney.  People's 
imaginations  get  to  work  at  once;  they  do  not  know 
where  that  kidney  may  "fetch  up."  I  have  found  people 
grievously  and  chronically  alarmed  over  this  matter. 
We  have  all  heard  of  people's  hearts  being  in  their 
throats,  and  I  think  they  sometimes  think  their  kid- 
ney is  there.  Floating  kidney  is  a  perfectly  harmless 
peculiarity  or  privilege,  not  a  disease,  and  sensible 

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DISEASES  OF  THE  KIDNEY 

doctors,  when  they  find  it,  keep  it  dark.  If  it  is  kept  dark 
it  practically  never  does  harm.  It  was  the  surgical 
fad  often  years  ago  to  operate  on  unfortunate  women 
and  tie  up  their  kidneys.  Now  it  is  rarely  done  except 
by  mistake. 

Tuberculosis  of  the  kidney  is  interesting  and  im- 
portant from  a  number  of  points  of  view.  The  first 
point  is  that  it  is  curable,  one  of  the  most  curable  forms 
of  tuberculosis.  For  tuberculosis  is  often  confined  to 
one  kidney,  and  when  it  is,  it  can  be  cured  by  the  re- 
moval of  that  diseased  kidney,  since  one  sound  kidney 
is  plenty  for  one  human  being.  I  do  not  know  of  any 
recovery  without  operation.  I  should  be  very  much 
interested  in  any  patient  who  had  a  well-founded  di- 
agnosis of  that  disease  and  had  got  well  without  opera- 
tion, but  I  should  be  very  critical  of  the  diagnosis.  We 
often  find  in  urine  a  harmless  germ  which  is  so  like  the 
tubercle  bacillus  that  there  are  very  few  people  who 
can  tell  the  difference :  in  such  cases  we  may  wrongly 
diagnose  tuberculosis,  and  later  wrongly  suppose  that 
we  have  cured  it.  The  disease  often  goes  very  far  in  one 
kidney  while  the  other  is  not  affected,  so  that  we  can 
safely  take  out  the  sick  kidney  and  leave  the  other. 

The  symptoms  of  tuberculosis  of  the  kidney  are  the 
next  point  of  special  interest  because  they  are  so  un- 
like what  we  might  suppose.  There  are  usually  no 
symptoms  over  the  kidney;  itie  symptoms  are  in  the 
bladder.  Tuberculous  kidney  shows  itself  chiefly  by 
frequent,  painful  urination.  Now  that  is  a  very  com- 

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mon  symptom  in  various  other  diseases,  and  even  in 
health.  It  is  not  in  itself  in  the  least  distinctive.  It 
may  come  simply  from  nervousness  or  because  people 
do  not  drink  enough  water  and  the  urine  is  too  concen- 
trated. Yet  frequent  and  painful  urination  is  the  symp- 
tom, and  often  the  only  symptom,  of  tuberculosis  of 
the  kidney.  A  physician  who  is  consulted  about  that 
symptom,  if  he  knows  his  job,  always  examines  the 
urine.  If  the  symptom  is  due  to  some  of  the  trifling 
causes,  the  urine  will  be  normal ;  if  it  is  due  to  tuber- 
culosis of  the  kidney,  the  urine  will  never  be  normal. 
The  physician  finds  in  the  urine  pus,  and  following  that 
up  he  looks  through  an  instrument  into  the  bladder  to 
see  where  that  pus  is  coming  from  (by  cystoscopy).  A 
small  tube  can  be  put  all  the  way  into  the  bladder,  and 
with  a  light  the  skilled  surgeon  can  see  exactly  what  is 
going  on  there.  What  he  sees,  in  tuberculosis  of  the 
kidney,  is  that  clear  urine  comes  down  through  one 
ureter,  and  pus  from  the  other.  When  he  sees  that,  he 
knows  the  first  thing  he  needs  to  know.  But  still  it  may 
be  non-tuberculous  pus  that  he  sees;  hence  the  next 
thing  that  he  does  is  to  put  through  the  cystoscope, 
into  the  ureter  through  which  the  pus  is  coming,  a 
still  smaller  tube,  and  thus  collect  that  pus  unmixed 
with  anything  else.  Then  he  looks  at  that  pus  for 
tubercle  bacilli.  If  he  finds  what  seem  to  be  tubercle 
bacilli,  he  may  still  be  wrong.  They  may  have  all  the 
marks  and  still  he  may  be  wrong.  But  there  is  one  in- 
valuable test,  and  that  is  the  guinea-pig.  This  disease 

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DISEASES  OF  THE  KIDNEY 

is  one  of  the,  to  me,  absolutely  convincing  reasons  for 
sacrificing  an  animal  for  the  benefit  of  human  beings. 
There  may  be  no  way  of  telling  whether  the  human 
being  has  tuberculosis  of  the  kidney  or  not,  unless  we 
put  some  of  this  pus  into  a  guinea-pig.  If  there  is  any 
tuberculosis  in  it,  the  pig  acquires  tuberculosis;  if  not 
he  remains  unharmed. 

If  the  " guinea-pig  test"  is  positive,  we  have  then  a 
full  chain  of  proof.  We  started  with  frequent  and  pain- 
ful micturition,  which  may  mean  anything  or  nothing. 
We  examined  the  urine  and  found  pus,  which  still  may 
not  be  serious.  We  cystoscoped  and  saw  the  pus  com- 
ing down  from  one  kidney  while  normal  urine  insur- 
ing a  sound  kidney  came  down  the  other  ureter.  We 
collected  the  pus  and  found  something  that  looked  like 
tuberculosis ;  not  satisfied  with  this,  we  put  some  of  the 
pus  into  a  guinea-pig  and  waited  six  weeks  —  which  is 
a  long  time,  but  seems  to  be  necessary.  Then,  and 
only  then,  are  we  ready  to  take  out  that  kidney  and  cure 
the  patient.  But  as  this  disease  goes  on  for  years  be- 
fore it  kills,  though  meantime  it  renders  a  person's  life 
perfectly  miserable,  the  loss  of  time  is  not  irreparable. 

If  the  pus  does  not  mean  tuberculosis,  it  might  be 
due  to  many  inflammations  of  the  kidney,  some  of 
which  would  not  require  operation.  A  pyelitis,  inflam- 
mation of  the  pelvis  of  the  kidney,  may  often  be  cured 
without  operation  by  giving  urotropin  and  an  abun- 
dance of  water.1 

1  See  page  177. 
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The  regular  hygienic  tuberculosis  treatments  (rest, 
food,  fresh  air)  should  all  be  carried  out  in  tuberculosis 
of  the  kidney  in  order  to  put  the  patient  in  good  condi- 
tion to  bear  the  operation.  It  should  also  be  done  to 
make  doubly  sure  that  we  are  allowing  no  other  tu- 
berculosis to  develop  elsewhere  in  the  body.  But 
hygienic  treatment  is  not  enough.  We  must  operate 
also.  I  have  not  seen  any  more  brilliant  cure  for 
disease  than  the  surgical  removal  of  a  tuberculous 
kidney. 

Frequent  painful  micturition  is  a  common  symptom 
in  women,  and  usually  harmless,  but  since  it  may  be 
due  to  this  painful  disease  it  is  of  great  importance 
that  the  urine  should  be  examined  and  all  these  other 
steps  carried  out  as  just  explained.  If  there  is  tuber- 
culosis in  both  kidneys,  so  that  we  cannot  remove  one, 
then  as  a  last  resource  we  use  the  tuberculin  treat- 
ment, not,  however,  with  very  much  hope.  This  type 
of  tuberculosis  in  both  kidneys,  like  the  various  other 
so-called  surgical  tuberculoses,  in  bone  or  joint  or 
gland,  deserves  also  the  same  hygienic  management  that 
helps  tuberculosis  in  the  lungs.  A  bill  was  introduced 
in  the  Massachusetts  Legislature  of  1916  to  ask  that 
we  have  a  sanatorium  for  non-pulmonary  tuberculosis. 
At  present,  if  we  want  to  get  a  patient  with  surgical 
tuberculosis  into  a  sanatorium,  we  have  to  go  to  some 
doctor  and  tell  him  please  to  find  something  the  matter 
with  the  patient's  lungs.  Sometimes  we  can  do  this 
and  sometimes  we  can't. 

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DISEASES  OF  THE  KIDNEY 

Pyelitis  (pyel  meaning  pelvis,  and  itis  inflammation), 
inflammation  of  the  pelvis  or  outlet  of  the  kidney,  is 
common  in  girl  babies  and  in  women  near  parturition, 
either  before  or  after.  It  also  occurs  in  other  people, 
but  not  nearly  so  commonly  as  in  these  two  groups.  It 
is  one  of  the  important  causes  of  unexplained  fever, 
and  when  a  child,  and  especially  a  girl  baby,  has  a 
fever  that  no  one  can  find  the  cause  for,  or  when  a 
woman  before  or  after  childbirth  has  a  fever  with  no 
apparent  cause,  it  often  turns  out  to  be  pyelitis.  It 
causes  no  local  symptoms  whatever;  as  a  rule  no  pain, 
no  trouble  with  the  passage  of  urine,  nothing.  It  can 
be  discovered  only  by  the  examination  of  urine,  but  it 
always  can  be  discovered  in  that  way.  It  usually  yields 
to  treatment  by  drugs  and  water.  There  are  ordinarily 
no  other  symptoms  except  fever ;  in  a  few  cases  there 
is  pain  over  the  kidney,  but  that  is  rare.  The  disease 
is  severe  enough  to  put  the  person  to  bed. 

I  remember  quite  vividly  a  little  baby  girl  in  our 
wards  whom  we  studied  without  finding  the  cause  of 
her  fever.  She  was  so  young  that  no  one  had  thought  of 
collecting  the  urine.  This  was  finally  done,  however, 
and  we  found  that  pyelitis  was  the  cause,  brought  down 
a  fever  which  had  lasted  for  weeks,  and  cured  the 
child  permanently,  simply  by  giving  urotropin  and 
water. 

The  other  diseases  of  the  kidney  it  is  not  in  my 
judgment  important  for  laymen  to  understand. 


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Diseases  of  the  Bladder 

Inflammation  of  the  bladder,  or  cystitis,  is  practi- 
cally always  due  to  some  trouble  outside  the  bladder. 
If,  for  example,  a  person  has  tuberculosis  of  the  kid- 
ney and  the  tubercle  bacilli  are  coming  down  the  ure- 
ter, they  often  implant  themselves  there  and  cause  a 
tuberculous  cystitis.  In  elderly  men  disease  of  the  pros- 
tate gland,  obstructing  the  bladder's  outlet,  causes 
cystitis.  But  what  fs  called  "simple  cystitis"  usually 
represents  simplicity  on  the  part  of  the  doctor  rather 
than  on  the  part  of  the  disease.  It  has  a  cause  outside 
the  bladder  and  the  doctor's  job  is  to  find  that  cause. 
Cystitis  shows  itself  by  the  symptoms  already  men- 
tioned in  renal  tuberculosis;  namely,  frequent,  painful 
micturition,  with  or  without  blood  and  demonstrable 
pus  in  the  urine.  It  is  a  common  result  of  gonorrhea, 
especially  in  women,  also  in  men.  It  very  commonly 
comes  after  childbirth  in  women,  or  as  a  result  of  any 
disease  in  which  a  catheter  has  to  be  used. 

A  catheter  is  a  small  tube  capable  of  passing  through 
the  urethra  into  the  bladder,  and  used  to  draw  urine 
when  it  cannot  be  passed  spontaneously.  Many  a 
patient  after  operation  cannot  pass  urine,  and  hence  it 
has  to  be  drawn  by  catheter.  Despite  aseptic  precau- 
tions it  is  impossible  to  pass  a  catheter  more  than  a  few 
times  without  infecting  the  bladder,  and  a  cystitis  re- 
sults, usually  clearing  up  when  we  can  get  the  patient 
to  passing  urine  without  a  catheter.  In  women  cystitis 

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DISEASES  OF  THE  BLADDER 

is  almost  always  curable,  because  in  them  the  chief 
cause  of  a  chronic  cystitis  is  tuberculosis  and  that  is 
curable.  In  men  it  is  often  curable  by  an  operation  on 
the  prostate  gland,  the  removal  of  the  obstruction  to 
the  bladder  outlet.  There  is  no  inflammation  of  the 
bladder  due  to  cold.  This  form  of  disease  can  exist 
for  a  long  time  without  poisoning  the  body.  So  acute 
an  inflammation  anywhere  else  would  be  very  likely  to 
result  in  blood  poisoning,  a  very  serious  danger  to  life. 
But  in  the  bladder  and  in  one  or  two  other  situations 
in  the  body,  such  as  the  naso-pharynx,  bacteria  and  pus 
can  exist  indefinitely  without  serious  danger  to  life, 
although  with  great  annoyance  to  the  patient. 

Connected  with  this  inflammation,  partly  as  cause, 
partly  as  result,  stones  may  form  in  the  bladder  and 
have  to  be  taken  out  at  operation. 

Tumors  of  the  bladder  are  luckily  rare ;  they  are  of  two 
types,  benign  and  malignant.  The  distinction  can  be 
made  only  by  the  microscope.  The  benign  tumor  can 
be  cured  by  electricity,  what  is  called  "fulguration," 
a  painless  process  somewhere  between  burning  and  ex- 
posure to  intense  light.  By  that  process  carried  on 
through  the  cystoscope,  benign  tumors  can  be  cured 
without  operation.  Malignant  tumors  are  almost  in- 
curable even  by  operation.  Whether  benign  or  ma- 
lignant, they  result  in  two  symptoms,  hematuria,  or 
bloody  urine,  and  pain  in  the  region  of  the  bladder. 
Persistent  bloody  urine  with  pain  is  usually  due  to 
tumor,  either  harmless  or  serious,  in  the  bladder  itself. 


CHAPTER  VIII 

DISEASES   OF   THE   GENERATIVE  ORGANS 

Female 

THE  commonest  tumor  of  the  uterus  is  the  so-called 
fibre-myoma,  ordinarily  called  "fibroid'*  of  the  uterus. 
It  is  a  benign  tumor,  not  cancer,  and  it  can  be  cured 
by  operation,  and  very  possibly  by  X-ray  without  op- 
eration, certainly  by  radium  in  some  cases.  Fibroid 
tumors  are  made  up  of  muscle  and  fibrous  tissue.  They 
often  exist  for  years  without  being  discovered  and  may 
never  need  any  treatment  at  all.  If  they  do  need  treat- 
ment it  is  for  one  of  the  following  reasons:  (i)  Because 
they  bleed;  in  some  cases  fibroid  tumors  lead  to  so 
continous  or  profuse  a  hemorrhage  that  the  patient 
is  exhausted  by  anemia.  (2)  Because  they  may  be  so 
large  that  the  weight,  dragging,  and  pressure  on  other 
organs  are  serious  and  demand  help.  (3)  Because  they 
may  interfere  with  pregnancy  or  childbirth.  (4)  Be- 
cause they  may  become  acutely  inflamed  or  strangu- 
lated. They  usually  cause  no  pain  and  never  spread 
to  any  other  organ  as  malignant  tumors  do.  They 
may,  by  their  wear  and  tear,  by  their  pressure  upon 
the  bladder,  for  instance,  and  upon  the  rectum,  cause 
bad  nervous  conditions. 

Because  the  uterus  is  so  close  to  the  bladder,  any 

180 


DISEASES   OF   THE    GENERATIVE    ORGANS 

tumor  of  this  kind  pressing  on  the  bladder  causes  fre- 
quent micturition,  and  is  a  bother  in  that  way.  It 
also  causes  constipation  by  pressure  on  the  rectum 
behind.  It  is  disputed  whether  fibroid  tumors  ever  be- 
come malignant.  I  do  not  think  there  is  any  good  evi- 
dence that  they  do.  Other  benign  tumors  may;  tumors 
in  the  breast,  for  instance.  A  malignant  tumor  is  not 
always  cancer.  There  are  a  number  of  microscopic 
distinctions  between  cancer  and  other  malignant 
tumors.  Malignant  tumors  are  always  fatal  unless 
operated  on,  and  often  even  if  they  are  operated  on. 

Fibroid  tumors  of  the  uterus  tend  to  shrivel  up  at, 
the  menopause,  and  that  is  important,  because  if  a 
woman  is  at  the  age  when  the  change  of  life  may  be 
shortly  expected,  she  may  be  encouraged  to  bear  her 
trouble  with  the  hope  that  it  will  not  last  very  long. 
On  the  other  hand,  in  a  young  woman,  one  cannot  en- 
courage hope  for  any  change  except  a  change  for  the 
worse  as  the  years  go  on.  Still,  if  there  is  no  hemor- 
rhage and  no  considerable  annoyance  from  pressure, 
the  tumor  is  rarely  important  except  when  the  question 
of  marriage  and  pregnancy  arises.  Fibroids  may  seri- 
ously interfere  with  pregnancy  and  endanger  the  life 
of  child  and  mother;  therefore,  in  a  young  woman,  if 
marriage  be  contemplated,  operation  may  be  attempted 
even  though  they  are  not  any  special  annoyance.  The 
larger  they  are  the  harder  it  is  to  remove  them.  When 
they  last  for  years  they  almost  always  become  adherent 
to  surrounding  organs,  to  the  bladder,  uterus,  and  in- 

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testine.   Operation  under  these  conditions  has  a  good 
deal  of  danger. 

The  operations  usually  done  are  two:  (i)  For  small 
fibroids,  to  try  to  take  them  out  of  the  uterus  without 
removing  the  uterus  (and  that  is  quite  often  possible). 
(2)  Rather  more  often  so  much  of  the  uterus  is  involved 
that  one  can  do  nothing  but  remove  it  wholly,  by  the 
operation  known  as  "hysterectomy."  Hysterectomy 
is  an  operation  always  involving  some  risk,  no  matter 
who  does  it,  or  under  what  conditions.  It  is  for  that 
reason  that  we  are  looking  very  eagerly  for  a  cure  for 
uterine  fibroid  through  X-ray  or  radium.  But  as  yet 
the  relative  merits  of  operation  and  radiotherapy  are 
not  settled. 

These  fibroid  tumors  are  extraordinarily  common  in 
the  negro  race.  We  generally  say  that  if  there  is  any- 
thing the  matter  with  a  negress  below  the  waist,  it  is 
safe  to  predict  that  she  has  a  fibroid.  We  know  noth- 
ing about  the  causation  of  tumors,  whether  benign  or 
malignant. 

The  insurance  companies,  who  need  to  be  right  for 
financial  reasons,  and  who  have  enormous  statistics, 
say  that  malignant  tumors  do  not  show  any  discover- 
able tendency  to  be  inherited.  It  is  well  to  know,  at 
any  rate,  that  some  of  the  best  authorities  think  that, 
and  that  no  one  can  positively  say  that  there  is  any 
danger  of  inheritance  of  cancer  or  any  other  tumor. 
I  am  personally  convinced  by  the  figures  submitted 
by  the  insurance  companies. 

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DISEASES    OF    THE    GENERATIVE    ORGANS 

Cancer  of  the  uterus  attacks  elderly  women  as  a  rule, 
and  is  not  apt  to  come,  as  fibroid  tumors  do,  at  any 
period  of  life.  It  usually  begins  in  the  neck  or  lower  ex- 
tremity of  the  uterus,  what  we  call  the  cervix,  and  pro- 
duces there  a  bloody  foul-smelling  discharge,  with,  or 
more  often  without,  pain.  It  is  very  apt  to  come  at  or 
after  the  change  of  life.  All  of  this,  of  course,  is  of  great 
importance  to  every  woman,  although  we  can  hold  out 
but  little  hope  of  cure  by  operation.  Still,  without  it  it 
is  one  hundred  per  cent  of  deaths.  No  one  ever  re- 
covered from  cancer  of  the  uterus  except  by  operation, 
and  although  I  cannot  say  that  I  have  ever  known  a 
cure  by  this  means,  other  people  have,  and  life  may,  at 
any  rate,  be  prolonged  by  removal  of  the  uterus,  which 
is  the  only  treatment.  X-ray  or  radium  has  never  cured 
a  case  so  far  as  I  know.  It  relieves  pain  in  some  in- 
operable cases,  and  so  may  be  of  value  when  operation 
is  impossible  or  is  refused. 

The  reason  that  I  have  to  speak  almost  hopelessly 
of  this  disease  is  that,  like  all  malignant  diseases,  it 
spreads  very  dangerously.  It  is  seldom  confined  to  the 
uterus  where  it  could  be  cured  by  removing  the  uterus. 
By  the  time  it  produces  any  symptoms  it  has  usually 
extended  into  deeper  and  perfectly  unreachable  parts. 
Untreated,  it  lasts  several  years,  generally  two  or  three. 

Surgeons  are  always  impressing  upon  us  the  neces- 
sity for  the  early  diagnosis  of  cancer  here  and  every- 
where, and  they  are  of  course  right.  But  we  must 
know  ourselves  and  confess  to  others  that  in  the  uterus 

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early  diagnosis  makes  less  difference  than  elsewhere,  be- 
cause we  have  so  little  hope  of  cure.  Still,  any  woman 
who  has  a  foul,  bloody  vaginal  discharge  at  or  near  the 
menopause  should  be  suspicious  of  cancer  and  have  an 
immediate  operation  if  the  suspicion  is  proved  correct 
by  expert  examination. 

So  few  women  know  these  facts  that  very  few  people 
have  ever  watched  for  signs  of  cancer,  and  it  may  be 
that  when  a  great  many  such  warnings  have  been 
noted,  we  shall  be  able  to  discover  it  soon  enough  to 
cure  it  by  operation.  Irregular  menstruation  does  not 
seem  a  symptom  worth  mentioning,  since  irregular 
menses  occur  in  many  other  diseases  and  without  any 
disease. 

Inflammation  of  and  through  the  uterus,  puerperal  -* 
poisoning  after  childbirth  is,  I  suppose,  the  next  most 
important  disease  of  the  uterus.  In  our  time  and  in 
communities  like  Boston,  we  see  and  hear  compara- 
tively little  of  it.  At  the  time  when  Dr.  Oliver  Wen- 
dell Holmes  wrote  his  classical  thesis  on  the  subject,  in 
1843,  it  was  a  very  large  factor  in  the  mortality  of 
Boston.  But  modern  obstetrics  has  nearly  eliminated 
puerperal  sepsis.  Nevertheless,  in  1913  it  caused  542 
deaths  out  of  a  total  of  890,848  in  the  "registration 
area"  of  the  United  States.  Puerperal  fever  means 
that  germs  travel  up  the  genital  canal  after  the  child 
has  passed  out,  and  infect  the  raw,  bleeding  surface. 
It  shows  itself  by  fever,  chills,  and  sometimes  by  tender- 
ness over  and  round  the  uterus,  with  a  foul  discharge. 

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DISEASES    OF   THE    GENERATIVE    ORGANS 

It  is  prevented  largely  by  cleanliness  on  the  part  of  the 
obstetrician  and  of  the  patient.  The  treatment  is  com- 
ing more  and  more  to  be  purely  hygienic  and  not  local. 
Very  few  good  obstetricians  to-day  try  to  clean  out 
the  uterus  or  to  apply  any  local  measure  in  simple 
puerperal  sepsis.  They  try  to  increase  the  patient's 
vitality  in  any  way  that  they  can. 
<  Serjsis  usually  appears  about  four  days  after  the 
baby  is  born.  The  mother  seems  to  be  doing  perfectly 
well  at  first;  then  slowly  the  temperature  begins  to 
rise  and  the  other  bad  symptoms  appear.  Probably 
the  mother's  condition  before  childbirth  has  much  to 
do  with  it.  If  she  were  in  poor  condition  her  resistance 
to  the  germs  must  be  less. 

/  Endometritis  is  not  at  all  an  important  disease  in  the 
vast  majority  of  cases;  but  it  is  a  term  so  often  heard 
that  we  must  know  it.  Endometritis  means  inflam- 
mation of  the  inside  of  the  uterus  (endo,  within ;  metra, 
uterus;  and  itis,  inflammation).  The  most  impor- 
tant form  of  it  is  that  which  forms  part  of  the  disease 
gonorrhea.  Gonorrhea  attacks  all  parts  of  the  female 
genital  organs,  and  along  with  this,  as  I  shall  mention 
later,  comes  inflammation  of  the  inside  of  the  uterus, 
with  a  discharge  of  pus.  The  diagnosis  is  made  by 
bacteriological  examination :  a  drop  of  pus  taken  from 
the  uterus,  if  stained  and  examined  under  the  micro- 
scope, will  usually  give  the  evidence  that  we  need  as  to 
the  origin  of  the  inflammation.  The  inflammation  it- 
self is  not  characteristic  aside  from  the  bacteriological 

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examination.  It  often  causes  no  symptoms  and  has  no 
important  results  unless  it  spreads  to  the  Fallopian 
tubes.  (See  salpingitis.) 

*Hy  per  plastic  endometritis  is  an  inflammation  ac- 
companied by  an  excessive  formation  of  tissue  in  the 
inside  of  the  uterus,  the  symptom,  and  the  only  symp- 
tom of  importance,  being  hemorrhage,  bleeding  at  or 
between  menstrual  periooTs.  It  is  for  this  that  curetting 
or  scraping  of  the  redundant  bleeding  tissue  inside 
the  uterus  is  most  often  justifiably  done.  Such  an  op- 
eration generally  gives  relief. 

Then  there  is  a  group  of  troubles  connected  with 
the  lower  segment  of  the  uterus,  the  cervix,  which  are 
again  mostly  matters  of  names  which  one  may  hear  used 
and  need  to  understand  though  they  are  not  very  im- 
portant to  the  patient.  Endocervicitis  is  inflammation 
of  the  inside  of  the  cervix  of  the  uterus.  Cervix  means 
neck.  This  is  a  common  cause  of  leucorrheal  discharge 
which  is  very  common,  both  as  a  symptom  of  debilityjC 
without  serious  disease,  and  as  a  part  of  disease  in  the 
uterus  itself.  The  endometritis  just  referred  to  may 
be  confined  to  the  neck  of  the  uterus  and  is  then  more 
definitely  endocervicitis. 

Then  the  term  erosion^  or  "ulceration"  of  the  cer- 
vix is  used  a  good  deal  accompanying  one  or  the  other 
types  of  endocervicitis  or  without.  Without  anything 
that  one  can  find  as  a  cause,  there  occurs  an  ulceration 
at  the  exit  of  the  uterus  which  gives  no  pain,  although 
it  looks  red  and  angry  and  produces  a  constant  dis- 

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DISEASES    OF   THE    GENERATIVE    ORGANS 

charge.  It  is  very  often  associated  with  tears  in  the 
neck  or  outlet  of  the  uterus  as  a  result  of  childbirth. 
These  are  often  spoken  of  as  lacerations,  a  long  word 
for  the  same  fact. 

With  practically  all  tears  there  is  more  or  less  erosion 
or  ulceration  such  as  I  have  just  mentioned.  There  is  a 
good  deal  of  difference  of  opinion  as  to  how  much  these 
tears  and  erosions  matter.  Some  physicians  feel  that 
they  constitute  a  considerable  factor  in  the  debility 
which  women  often  have  to  suffer  from  a  multitude  of 
causes.  They  believe  that  endocervicitis,  tears,  and 
erosions  about  them,  while  not  in  themselves  very  im- 
portant (as  practically  any  physician  would  to-day 
admit),  are  still  an  important  though  minor  factor  in 
pulling  down  health.  I  do  not  think  so  myself,  but  I 
recognize  that  there  is  room  for  difference  of  opinion 
about  them.  I  have,  in  a  good  many  years*  service  at 
the  Massachusetts  General  Hospital,  seen  them  in  hun- 
dreds and  hundreds  of  women,  who  seem  to  suffer  no 
harm  from  their  existence  through  months  and  years. 

Even  the  public  hears  nowadays  a  good  deal  about 
the  " cervix-and-perineum  operation"  for  the  repair  of 
tears  both  in  the  neck  of  the  uterus  and  at  the  outlet  of 
the  vagina,  —  tears  due  to  the  process  of  childbirth. 
The  last  of  these,  lacerations  of  the  perineum,  are  cer- 
tainly a  cause  of  trouble,  because  they  leave  the  pelvic 
organs  without  proper  support  from  below,  so  that  the 
pelvic  organs  get  very  low,  pull  upon  their  supports 
above,  and  give  an  uncomfortable  sense  of  dragging 

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and  pain.  Hence,  when  a  cervical  tear  is  accompanied 
by  a  perineal  tear,  the  combination  may  be  important 
and  it  may  be  difficult  to  say  that  the  cervical  does  not 
add  somewhat  to  the  trouble. 

A  further  possible  importance  of  cervical  tears  and 
ulcerations  is  that  it  is  believed  by  some  physicians 
that  chronic  ulcerations  of  the  cervix  of  the  uterus 
lead  to  cancer.  I  must  also  say  that  it  is  believed  by 
some  that  they  do  not  lead  to  cancer.  The  latter  is  my 
own  belief. 

Many  physicians  say  that  all  tears  of  the  cervix 
should  be  repaired,  provided  the  woman  is  not  to  have 
more  children.  If  she  has  come  to  that  time  of  life,  all 
cervical  tears  should  then  be  repaired  (some  say)  be- 
cause if  not  repaired  they  may  lead  to  cancer.  It  is  per- 
fectly foolish  to  repair  a  tear  in  a  woman  who  is  going 
to  have  more  children,  because  it  is  sure  to  tear  out 
again. 

Cervical  tears  are  often  of  importance  to  determine 
the  question  whether  a  woman  has  ever  been  pregnant. 
I  have  found  them  a  number  of  times  in  women  who 
denied  pregnancy  and  thus  had  a  much  more  definite 
proof  than  would  otherwise  have  been  possible.  Cervi- 
cal tear  never  occurs  from  any  other  cause. 

I  will  put  in  here  what  I  have  to  say  in  relation  to 
evidences  of  virginity.  The  presence  of  the  hymen, 
the  membrane  which  nearly  closes  the  entrance  of  the 
vagina,  has  often  been  taken  as  evidence  of  virginity; 
never,  however,  rightly.  In  a  virgin  the  hymen  may 

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DISEASES   OF   THE    GENERATIVE   ORGANS 

be  practically  absent,  may  be  so  stretched  or  so  slight 
that  it  amounts  to  nothing.  Moreover,  it  may  be  torn 
without  a  person's  ever  having  had  sexual  intercourse; 
no  physician  to-day  in  any  medico-legal  case,  goes  by 
the  condition  of  the  hymen  where  it  is  important  that 
he  should  be  right.  Any  woman  who  has  ever  had  a 
pelvic  operation  or  had  gynecological  instruments  used, 
is  likely  to  have  tears  in  the  hymen  which  might  be 
very  falsely  interpreted. 

The  Fallopian  tube  is  the  passage  leading  from  the 
uterus  nearly,  but  not  quite,  to  the  ovary. 
^Salpingitis,  inflammation  of  the  Fallopian  tube,  is 
often  called  pyosalpinx  —  which  is  a  little  more  defi- 
nite, and  means  an  inflammation  that  makes  pus.  A 
familiar  term  for  that  last  is  "pus  tube,"  and  physi- 
cians often  say  or  write  in  textbooks,  "At  operation 
we  found  a  tube."  I  have  known  patients  to  be  much 
worried  about  this,  thinking  that  the  surgeon  had 
found  that  somebody  had  left  a  drainage  tube  in  the 
body  at  a  previous  operation.  But  the  phrase  merely 
means  an  inflammation  of  the  Fallopian  tube. 

This  is  the  most  important  of  the  effects  of  gonor- 

jsrhea  in  women.  Gonorrhea  is  not  the  only  cause  of  sal- 

pingitis,  but  it  is  much  the  commonest  and  much  the 

most  serious  form.  Salpingitis  produces  two  important 

results :  — 

(i)  It  seals  up  the  Fallopian  tube.  This  is  the  com- 
monest cause  of  sterility  in  women.  When  the  tube  is 
closed,  the  ovum  or  seed  cannot  pass  down  to  the  uterus 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

nor  meet  with  the  spermatozoa.  That  in  itself,  obliter- 
ating salpingitis  of  one  tube,  does  not  always  cause 
symptoms.  It  may  mean  merely  the  sealing  of  this 
little  tube  which  is  smaller  than  a  piece  of  chalk.  Being 
closed,  it  may  not  hurt  the  woman  at  all,  but  the  steril- 
ity is  of  course  a  great  misfortune  to  her. 

(2)  The  other  result  is  the  formation  of  pus  in  and 
around  the  tube.  This  is  perhaps  the  commonest  and 
most  troublesome  of  all  diseases  that  are  peculiar  to 
women.  It  produces  the  familiar  symptoms  of  in- 
/  flammation,  namely,  pain,  tenderness,  and  a  fever  with 
a  long-drawn-out  course  extending  over  weeks  and 
months,  often  with  relapses.  Doctors  speak  of  it  as 
"flaring  up "  now  and  then,  as  they  do  of  tuberculosis. 
Finally  comes  either  spontaneous  healing  through  the 
formation  of  scar  tissue  and  the  absorption  of  the  pus, 
or  the  breaking  into  some  of  the  surrounding  tissues, 
especially  the  peritoneum  with  virulent  and  sometimes 
fatal  peritonitis.  The  last  is  rare  because  either  healing 
or  operation  usually  prevents  it,  but  even  after  opera- 
tion there  are  a  good  many  deaths.  The  operation  for 
pus  tube  is  often  a  serious  and  difficult  one  and  is  not 
necessarily  a  cure. 

Because  this  inflammation  is  of  so  long  standing,  it 
has  the  usual  result  of  long-standing  inflammations,  in 
adhesions,  so  that  the  tubes  stick  to  the  surrounding 
parts.  The  tube  becomes  adherent  to  the  ovary,  or  to 
the  rectum,  or  to  other  portions  of  the  intestine.  This 
is  sometimes  important  both  as  a  cause  of  symptoms, 

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DISEASES   OF   THE    GENERATIVE    ORGANS 

such  as  pain  and  constipation,  and  also  as  making  the 
operation  for  removing  the  tube  a  very  difficult  one, 
for  the  operation  means  trying  to  separate,  with  the 
finger  or  with  instruments,  adhesions  which  may  tear 
into  the  bowel  at  any  minute  and  through  whose  tear- 
ing we  may  have  a  serious  peritonitis.  Surgeons  are 
operating  on  these  cases  less  and  less;  there  are  not 
half  as  many  operations  of  this  kind  as  there  used  to 
be  fifteen  or  even  ten  years  ago.  It  is  recognized  that 
if  we  put  the  patient  to  bed  and  do  what  we  can  to  in- 
crease her  vigor,  she  will  usually  live  4own  the  inflam- 
mation, and  get  as  good  a  result  as  operation  could 
achieve.  The  inflammation  will  generally  seal  up  the 
tube,  but  that  is  not  any  worse  than  what  will  happen 
anyway,  as  operation  involves  removing  the  tube. 

Chronic  invalidism  in  women  following  marriage, 
with  dragging,  pain,  and  fever,  is  very  often  due  to 
this  disease ;  probably  more  often  than  any  other  one 
trouble.  It  is  apt  to  come  soon  after  marriage,  because 
that  is  the  time  when  infection  by  gonorrhea  is  most 
apt  to  occur.  In  such  cases  the  husband  supposes  him- 
self to  have  been  cured  long  ago  of  gonorrhea,  but  has 
not,  in  fact,  been  cured. 

In  relation  to  social  work  the  importance  of  this  dis- 
ease is  that  it  means  a  long,  tedious  illness,  usually 
without  danger  to  life,  but  usually  with  permanent  im- 
pairment, more  or  less  marked,  of  vigor  and  the  ability 
to  do  what  healthy  people  can.  There  is  almost  always 
some  trouble  due  to  the  adhesions.  Operation  does  not 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

prevent  these  adhesions  —  it  often  produces  more, 
adding  to  what  were  there  already,  so  that  we  have  no 
way  of  escaping  that.  Operation  only  safeguards  the 
patient  against  peritonitis  of  a  more  widespread  and 
dangerous  type,  and  is  now  usually  performed  only 
when  this  danger  seems  imminent. 

As  a  part  of  salpingitis  the  patient  has  what  is 
called  "  pel  vie  peritonitis,"  or  inflammation  of  that 
part  of  the  peritoneum  which  dips  down  into  the 
pelvis.  As  long  as  it  is  confined  to  that  region  the  peri- 
tonitis is  not  serious.  It  is  only  when  it  becomes  general 
peritonitis,  when  it  spreads  to  the  rest  of  the  abdomen, 
that  it  is  a  serious  menace  to  life.  The  word  "  peri- 
tonitis" means  very  different  things  from  the  point  of 
view  of  seriousness.  General  peritonitis  is  one  of  the 
most  fatal  of  diseases.  Pelvic  peritonitis  is  enormously 
common,  but  practically  never  fatal,  because  local. 

It  is  a  mistake  to  suppose  that  all  cases  of  pus  tube 
are  due  to  gonorrhea.  We  probably  never  shall  know 
what  proportion  are  caused  in  that  way,  because  the 
results  of  bacteriological  examination  of  pus  found  at 
operation  is  not  conclusive.  One  may  find  the  organ- 
ism of  gonorrhea,  but  if  one  does  not  find  it  one  is  not 
by  any  means  sure  that  it  is  not  there.  We  are  sure 
that  some  cases  of  salpingitis  are  not  due  to  gonorrhea 
—  we  cannot  say  how  many.  Hence  it  is  important 
not  to  assume  that  merely  because  a  woman  has  had  a 
pus  tube  she  has  had  gonorrhea. 

The  only  other  type  of  pus  tube  or  salpingitis  to 

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DISEASES   OF   THE   GENERATIVE   ORGANS 

which  we  can  give  a  definite  name  is  the  tuberculous 
type,  quite  a  different  affair,  more  common  in  young, 
unmarried  women  than  in  older  women.  It  rarely 
remains  local  but  generally  spreads  to  the  rest  of  the 
peritoneum.  /-  * 

Aside  from  surgery  we  have  no  important  remedies 
for  the  diseases  that  I  have  been  going  over,  except 
hygiene  and  rest.  We  have  no  medicines  that  have 
any  considerable  effect,  and  the  great  bulk  of  medical 
opinion  to-day  is  against  local  applications  and  medica- 
tions, of  which  there  has  been  a  vast  deal  in  the  past, 
most  of  us  think  with  less  than  no  good.  That  is, 
gynecology,  or  the  specialty  that  deals  with  diseases 
of  the  female  genital  organs,  is  to-day  not  a  specialty, 
but  a  branch  of  surgery,  so  far  as  it  is  a  legitimate, 
honorable  part  of  medicine.  We  are  proud  that  we 
have  no  department  of  gynecology  in  the  Massachu- 
setts General  Hospital,  and  we  are  firmly  determined 
that  there  shall  be  none.  To  make  gynecology  a  spe- 
cialty or  a  separate  department  is  to  attempt  an  impos- 
sible subdivision  within  the  field  of  surgery,  because  no 
one  can  know  the  surgery  of  the  pelvic  organs  who  does 
not  know  the  surgery  of  the  whole  abdomen.  As  a 
matter  of  fact,  "gynecologists"  of  the  type  of  Kelly, 
include  in  their  domain  the  gall-bladder  and  appendix, 
the  kidney,  and  sometimes  the  breast.  Gynecologists 
have  long  since  given  over  any  attempt  to  define  their 
province  strictly  and  by  their  practice  maintain,  what  I 
have  just  said,  that  no  one  can  be  a  good  surgeon  in  any 

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part  of  the  body  without  being  a  good  general  surgeon. 
There  used  to  be  a  so-called  medical  gynecology,  but 
we  are  convinced  that  there  should  be  no  such  thing. 
It  means  the  application  of  remedies  to  an  eroded 
surface,  the  application  of  medicated  cotton  and  such 
things  to  the  vicinity  of  an  inflamed  tube,  putting  in 
what  is  called  " packing"  in  a  quite  useless  attempt 
to  bring  a  displaced  uterus  up  into  position.  These 
procedures  keep  a  woman  coming  for  treatment,  with 
great  harm  to  her  pocket-book  and  often,  I  think,  to 
her  character. 

There  is  a  difference  of  opinion  among  physicians  as 
to  the  possible  use  of  an  instrument  that  is  called  a 
" pessary."  A  pessary  is  a  hard  or  soft  rubber  instru- 
ment intended  to  help  keep  the  uterus  in  proper 
position  or  to  bring  it  up  into  position.  But  since  the 
uterus  has  no  one  proper  position  it  becomes  rather 
hard  to  find  the  usefulness  of  a  pessary.  The  practi- 
cal point,  however,  is  this:  a  considerable  number  of 
women,  for  reasons  unknown  to  me,  are  more  com- 
fortable using  this  instrument.  I  have  again  and  again 
found  a  woman  wearing  a  pessary  which  had  not  done 
anything  whatever  except  erode  the  walls  of  the  va- 
gina, and  which  yet  she  clung  to  as  giving  her  a  comfort 
she  could  not  get  along  without.  No  one  can  state 
what  good  the  pessary  does,  but  it  can  be  stated  that  it 
certainly  makes  some  women  more  comfortable.  As 
long  as  this  is  so  it  will  probably  be  used. 

I  object  to  the  word  "gynecologist"  because  I  think 

194 


DISEASES   OF   THE    GENERATIVE    ORGANS 

it  sounds  as  if  there  were  a  legitimate  specialty  of  that 
kind.  I  think  there  is  a  specialty,  but  not  a  legitimate 
specialty  of  that  kind.  We  tend  to  look  askance  at 
people  to-day  who  call  themselves  gynecologists,  and 
very  few  physicians  do,  not  nearly  so  many  as  ten  or 
even  five  years  ago.  It  is  beginning  to  be  felt  to  be  a 
somewhat  dubious  word.  It  is  parallel  to  the  man  who 
calls  himself  a  stomach  specialist.  There  never  can  be 
such  a  thing,  because  no  human  being  can  understand 
the  stomach  unless  he  understands  every  one  of  the 
other  organs  in  the  body  so  far  as  modern  medicine 
can  enable  him  to  do  ;  if  he  does,  he  cannot  truthfully 
call  himself  a  specialist. 

That  does  not  mean,  of  course,  that  a  man  may  not 
give  more  time  to  the  study  of  one  organ  than  another 
man  does,  but  it  does  mean  that  all  surgeons  should 
call  themselves  surgeons,  their  skill  resting  upon  a 
general  training,  as  well  as  upon  a  special  training. 


When  women  have  borne  many  children,  and  some- 
times when  they  have  not,  if  they  have  been  obese, 
the  walls  of  the  vagina  become  relaxed  so  that  they 
hang  down  and  protrude  at  the  orifice.  If  it  is  the  an- 
terior wall  next  to  the  bladder,  we  call  this  a  cystocele; 
if  the  posterior  wall  next  to  the  rectum,  we  call  it  a 
rectocele;  and  the  two  practically  always  go  together  as 
minor  ailments  along  with  torn  cervix  and  perineum. 
All  of  these  ailments  are  often  present  in  a  single  case. 

In  the  vast  majority  of  cases  treatment  of  these  con- 

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ditions  is  unsatisfactory.  I  know  nothing  I  have  seen 
more  disappointment  about  than  when  a  woman  has 
been  persuaded  to  go  to  a  hospital  and  be  operated 
on  for  the  relief  of  these  troubles,  and  then  finds  herself 
in  just  the  same  condition  as  before.  I  should  not 
like  to  say  that  good  cannot  be  done  by  operations  for 
cystocele  and  rectocele,  but  I  have  never  seen  it  done. 

Then  there  is  prolapse  of  the  uterus,  or  dropping  of 
the  whole  organ.  It  results  from  a  weakening  of  the 
supports  and  ligaments  of  the  uterus  in  women  who 
have  borne  many  children,  who  are  generally  obe^se, 
and  have  been  on  their  feet  a  great  deal  doing  hard 
work.  The  uterus  descends  toward  the  opening  of  the 
vagina  and  may  actually  protrude.  This  generally 
does  no  harm,  but  if  there  is  actual  protrusion  there 
may  be  much  inconvenience  and  some  operation  may 
have  to  be  done.  The  operation  for  this  is  more  satis- 
factory than  for  cystocele  and  rectocele,  although  I  do 
not  think  any  one  can  say  that  it  is  brilliantly  success- 
ful, as  the  trouble  is  apt  to  recur. 

Vaginitis,  inflammation  of  the  vagina,  is  practically 
always  gonorrheal.  In  the  adult  it  is  practically  always 
caught  in  the  act  of  sexual  intercourse ;  in  a  child  —  the 
vulvo-vaginitis  of  little  girls  —  it  is  usually  innocent, 
due  to  the  same  organism,  the  gonococcus,  but  usually 
in  young  children  not  to  any  fault  on  the  part  of  the 
child.  It  is  caught  in  such  children  in  some  way  from 
their  parents,  perhaps  through  bed-linen,  perhaps 
through  sponges  or  towels.  I  do  not  think  we  know. 

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DISEASES   OF   THE    GENERATIVE    ORGANS 

It  is  extraordinarily  contagious  from  adult  to  child  and 
from  child  to  child;  it  is  extraordinarily  lacking  in 
contagion  from  child  to  adult. 

A  child  with  vulvo-vaginitis  in  a  hospital  ward  with 
other  children,  even  though  the  greatest  pains  is  taken 
to  prevent  contagion,  often  spreads  contagion  to  the 
other  children  in  very  mysterious  ways.  But  such  a 
child  practically  never  spreads  that  contagion  to  an 
adult,  and  this  is  often  of  importance  in  relation  to  the 
propriety  of  placing  out  such  a  child  in  a  family  of 
adults.  So  far  as  contagion  is  concerned,  it  is  perfectly 
safe  to  place  out  a  child  with  this  disease  with  adults. 
It  is  not  safe  to  put  an  infected  child  with  other  chil- 
dren. It  may  be  impossible  to  prevent  contact  with 
other  children,  but  we  should  do  all  we  can  to  prevent  it. 

In  the  adult  this  vaginitis  almost  always  spreads  up 
into  the  uterus  and  tubes,  with  the  results  that  I  have 
already  described,  endometritis,  salpingitis,  etc.  In 
the  child  it  almost  never  does  so  spread ;  in  spite  of  the 
enormous  number  of  cases  studied  of  late  years,  there 
are  very  few  reliable  reports  of  this  disease  spreading 
upwards  and  doing  any  harm.  It  is  a  local  affair  and 
not  a  serious  one  to  the  health  of  the  child  as  a  rule. 
This  does  not  mean  that  it  should  not  be  treated,  but 
that  we  need  not  fear  any  such  results  as  we  always 
fear  in  an  adult.  Children  always  recover  with  time, 
but  it  is  sometimes  a  slow  business.1  They  recover 
without  treatment,  but  it  may  take  years. 

1  See  page  361. 
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Gonorrhea  in  older  women  is  even  more  difficult  to 
cure,  and  it  is  very  difficult  to  say  that  one  has  ever 
seen  a  case  cured  as  a  result  of  treatment.  We  see  its 
acute  symptoms  get  well,  often  after  a  lapse  of  many 
months,  but  we  seldom  see  it  improve  much  faster 
under  treatment. 

Ovarian  Disease.  An  enormous  amount  of  disease 
referred  to  the  ovary  does  not  belong  there.  As  soon  as 
women  begin  to  learn  a  little  anatomy  and  to  become 
conscious  of  pain  in  this  part  of  the  body  they  are  apt 
to  think  there  is  something  wrong  with  the  ovaries. 
But  the  evidence  of  ovarian  disease  is  very  difficult  to 
obtain  until  after  operation,  and  in  very  few  cases 
except  ovarian  tumors  can  we  be  sure  of  it.  The  self- 
made  diagnoses  of  disease  or  pains  in  the  ovaries  are 
likely  to  be  wrong.  Most  of  the  cases  called  ovarian 
are  really  matters  involving  the  Fallopian  tube,  or  the 
appendix,  or  the  muscles  of  the  abdomen,  or  the  bones 
in  the  back,  or  something  else  that  has  no  special  con- 
nection with  the  pelvis. 

Beyond  any  doubt  the  most  important  ovarian 
disease  is  tumor,  for  the  ovaries  are  very  subject  to 
tumors  and  especially  to  benign,  harmless  tumors. 
These  tumors  are  thin-walled,  bladder-like  affairs,  full 
of  a  jelly-like,  thick,  syrupy  fluid.  In  old  times,  when 
surgeons  were  less  bold,  ovarian  cysts  grew  to  enor- 
mous size  before  any  cure  was  attempted  —  as  big  as 
a  bushel  basket.  To-day  we  do  not  often  see  these  tu- 
mors because  they  are  operated  on  when  smaller.  They 

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DISEASES    OF    THE    GENERATIVE    ORGANS 

are  cured,  so  far  as  we  know,  only  by  operation,  and 
there  is  no  need  of  operation  unless  they  are  so  large  as 
to  be  inconvenient.  As  I  have  said,  they  are  benign, 
they  do  not  mean  cancer,  they  do  not  have  any  serious 
danger  to  life,  and  may  be  let  alone  aside  from  the 
inconvenience  of  their  size,  and  the  pressure  on  the 
bladder  or  adjacent  organs.  Although  they  start  on 
one  side  as  a  rule,  they  soon  grow  toward  the  median 
line  and  may  fill  up  the  whole  abdomen.  The_syjnp- 
toms  are  a  sense  of  pressure  and  weight  as  described  in 
fibroid  of  the  uterus.  Smaller  ovarian  cysts,  the  size  of 
the  finger  end,  are  often  found  at  operation  for  some- 
thing else.  They  are  harmless. 

It  is  a  very  serious  thing  to  take  out  both  ovaries,  — 
not  serious  to  life,  but  serious  to  health,  —  and  physi- 
cians are  much  more  aware  of  that  to-day  than  they 
were.  Also  the  better-educated  physicians  are  more 
aware  of  it  than  the  less-educated.  The  ovaries  used  to 
be  removed  for  a  great  many  causes,  but  this  is  not  so 
any  longer.  I  have  seen  a  good  many  women  who  have 
had  this  operation  done  for  nothing  more  than  nervous- 
ness —  persistent  nervous  trouble  which  was  attrib- 
uted to  ovarian  disease,  the  ovaries  removed,  and  the 
woman  much  the  worse.  The  idea  that  troubles  at 
a  distance,  backaches,  stomach  troubles,  headaches, 
neurasthenic  symptoms,  might  be  due  to  disease  of  the 
ovary,  was  very  prevafent  at  one  time,  and  is  to-day,  I 
think,  pretty  nearly  gone.  Removal  of  the  ovaries  has 
a  very  different  effect  from  the  natural  cessation  of 

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their  function  at  the  "change  of  life."  Many  a  woman 
is  much  stronger,  healthier,  happier,  after  the  change 
of  life  than  before,  but  I  do  not  know  that  that  can  be 
said  ever  —  certainly  not  often  —  of  a  woman  in  whom 
the  ovaries  are  removed  earlier.  Of  course  they  may 
have  to  be  removed,  but  as  a  rule  nervous  symptoms, 
lack  of  control,  lack  of  balance,  are  accentuated,  not 
helped,  by  the  removal  of  the  ovaries. 

I  am  saying  this  because  women  talk  these  things 
over  with  other  women  and  with  social  workers,  and 
ought  to  have  some  knowledge  as  to  the  consequences 
of  this  operation.  Of  course,  if  the  uterus  has  to  be 
removed,  as  in  fibroid  tumors  or  cancer,  there  is  no 
particular  use  in  leaving  the  ovaries  and  they  are  usu- 
ally removed,  too,  but  some  men  are  doubtful  even 
about  that.  To-day  one  finds  every  effort  to  leave  one 
ovary  or  at  least  a  part  of  one,  because  of  its  good 
effect  on  the  general  health.  We  are  quite  sure  to-day 
that  the  ovary  has  another  function  than  that  of  pro- 
ducing eggs.  It  has  an  internal  secretion,  i.e.,  a  power 
to  send  into  the  blood,  and  through  the  blood  supply 
to  the  whole  body,  something  that  the  body  needs.  We 
do  not  know  much  more  than  that.  We  do  know  that 
[the  ovary  has  a  very  valuable  function  in  preserv- 
;ing  general  health,  and  that  we  must  not  remove  the 
possibility  of  that  function  unless  for  compelling 
reasons. 

Malignant  tumors  of  the  ovary  are  rare,  but  have 
the  same  ominous  prognosis  and  the  same  purely  surgi- 

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DISEASES   OF   THE    GENERATIVE   ORGANS 

cal  treatment  as  malignant  tumors  anywhere  else.  No 
layman  can  suspect  their  presence. 

Prolapse  or  downward  displacement  of  the  ovary  is 
one  of  the  minor  gynecological  ailments  for  which 
nothing  should  be  done,  which  is  the  source  of  a  great 
deal  of  meddlesome  and  harmful  treatment.  Inflam- 
mation of  the  ovary  is  very  rare  and  unimportant 
except  as  a  minor  part  of  salpingitis. 
^»Extra-uterine  pregnancy.  I  said,  in  describing  the 
normal  process  of  pregnancy,  that  the  egg  might  join 
the  spermatozoon,  become  fertilized,  take  root,  and  go 
on  toward  the  development  of  a  child,  not  in  the 
uterus,  its  proper  place,  but  in  the  tube.  That  is  not 
at  all  rare.  It  is  what  we  call  extra-uterine  pregnancy 
or  ectopic  gestation.1  A  woman  finds  that  she  has 
some  or  all  of  the  minor  signs  of  pregnancy,  which  are, 
in  the  first  place,  the  cessation  of  menstruation ;  in  the 
second  place,  a  morning  nausea  or  vomiting  extending 
from  about  the  second  to  about  the  fourth  month  of 
pregnancy;  in  the  third  place,  changes  in  the  breasts, 
with  enlargement  and  greater  sensitiveness,  some- 
times darker  color  around  the  nipples.  Those  symp- 
toms are  the  same  in  ectopic  gestation  as  in  normal 
pregnancy,  but  there  come  in  addition  sudden  attacks 
of  sharp  pelvic  pain,  which  may  also  occur  in  normal 
pregnancy  but  rarely  do. 

The  diagnosis  is  difficult,  only  to  be  made  by  physi- 

1  EC  means  out  of;  topic  means  place  (topos}\  gestation  or  pregnancy 
out  of  place. 

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cal  examination,  and  even  then  the  diagnosis  between 
extra-uterine  pregnancy  and  pus  tube  is  sometimes 
very  difficult.  They  both  produce  many  of  the  same 
symptoms  and  they  do  not  either  of  them  have  a  clear- 
cut,  invariable  picture.  The  fear  that  is  entertained  is 
that  as  the  fertilized  egg  grows,  it  may  burst  the  tube 
with  sudden  and  sometimes  fatal  hemorrhage.  In  a 
person  who  has  had  symptoms  such  as  I  have  de- 
scribed, an  attack  of  pain  accompanied  by  faintness, 
by  great  weakness,  by  pallor,  which  are  the  signs  of 
hemorrhage,  is  very  serious  and  calls  for  immediate 
skilful  surgery  if  life  is  to  be  saved.  But  life  can  be 
saved  in  the  great  majority  of  cases  by  prompt  surgery. 

The  surgeon  stops  the  hemorrhage  and  removes  the 
tube  with  the  fetus.  As  a  rule  there  are  no  bacteria 
concerned,  no  sepsis,  and  so,  if  the  operation  can  be 
done  promptly  and  no  mistake  is  made,  the  patient 
may  perfectly  well  recover  and  pregnancy  take  place 
in  the  normal  way  from  the  other  tube. 

We  have  no  idea  of  the  cause  of  tubal  pregnancy,  or 
method  of  its  prevention.  So  far  as  we  know  it  will 
happen  once  in  so  often  as  long  as  life  goes  on.  A 
woman  in  whom  such  a  thing  has  happened  is  a  little 
more  apt  to  have  it  occur  again. 

It  is  not  the  same  as  abdominal  pregnancy  (devel- 
opment of  the  fetus  in  the  abdomen  outside  the  pelvis). 
That  is  much  rarer  and  usually  is  not  recognized,  since 
it  is  considered  to  be  either  normal  pregnancy  or  a 
tumor. 

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DISEASES  OF  THE    GENERATIVE    ORGANS 

The  diagnosis  of  pregnancy,  either  normal  or  ab- 
normal, is  generally  easy;  occasionally  very  difficult. 
I  have  seen  the  best  experts  mistaken  occasionally. 
The  confusion  is  generally  between  pregnancy  and 
some  tumor,  some  other  cause  for  enlargement  of  the 
abdomen,  and  with  tumors  sometimes  there  comes  the 
cessation  of  menstruation  because  menstruation  may 
stop  from  any  cause  that  weakens  the  whole  organism. 

The  Hygiene  of  Pregnancy.  The  urine  should  be 
examined  every  month  and  in  the  last  half  of  preg- 
nancy every  week.  The  blood  pressure  should  be  meas- 
ured at  similar  intervals.  Varicose  veins  may  develop 
in  the  legs  and  may  need  support  by  bandaging  as 
described  on  page  81. 

In  most  ways  the  woman  should  live  and  behave 
like  other  sensible  women,  with  regular,  moderate 
exercise,  abundant  sleep,  plentiful,  well-balanced  diet, 
suitable  recreation,  and  such  occupations  as  favor 
tranquillity  and  self-forgetfulness.  It  is  a  mistake  for 
a  woman  to  treat  herself  like  an  invalid,  but  especially 
in  the  latter  months  horseback  riding  and  other  vio- 
lent exercise  should  be  avoided,  —  also  falls  and  jolts 
of  any  kind,  mental  or  physical. 

In  the  latter  months  of  pregnancy  it  is  important 
that  the  woman  should  remember  that  she  must  eat 
enough  to  nourish  her  baby  as  well  as  herself.  Extra 
lunches  between  meals  or  milk  with  meals  is  sufficient. 
It  is  customary  to  advise  the  drinking  of  six  or  eight 
glasses  of  water  daily. 

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Regular  visits  to  a  physician  should  be  made  in  the 
last  half  of  pregnancy  in  order  to  forestall  eclampsia, 
—  the  self-poisoning  which  results  in  convulsions,  un- 
consciousness, and  often  death  soon  before  or  after  the 
birth  of  the  child. 

Pernicious  vomiting  of  pregnancy  —  and  the  result 
of  self-poisoning  —  occurs  in  the  earlier  months  as  a 
rule  and  is  simply  an  exaggeration  of  the  morning 
nausea  experienced  by  most  pregnant  women.  Re- 
maining in  bed  until  after  the  first  meal  is  taken,  and 
remaining  very  quiet  afterwards,  nips  some  cases  in 
the  bud,  but  a  physician  should  always  be  called  upon 
to  decide  the  diet  and  daily  regime. 

Severe  anemia,  toxic  goitre,  and  insanity  are  other 
occasional  complications  of  pregnancy.  The  rules  of. 
hygiene  above  given  are  usually  all  we  can  do  to  avert 
such  dangers. 

Disturbance  in  the  function  of  menstruation.  Men- 
struation is  especially  apt  to  stop  soon  after  it  has 
begun  for  the  first  time;  that  is,  in  girls  who  have  just 
begun  to  have  this  function,  it  is  apt  to  be  irregular 
quite  often  for  the  first  year  or  two  before  it  is  thor- 
oughly established.  This  may  mean  no  disease ;  simply 
fatigue  or  low  condition  from  any  cause.  When  men- 
struation has  been  established,  it  is  apt  to  be  checked 
by  any  great  shock  to  the  mind  or  by  any  serious  dis- 
ease of  the  body.  I  have  known  a  good  many  immi- 
grant girls  whose  menstruation  stopped  simply  be- 
cause they  crossed  the  ocean,  and  perhaps  because 

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DISEASES  OF  THE   GENERATIVE   ORGANS 

they  were  homesick.  If  one  is  convinced  that  preg- 
nancy and  organic  disease  are  absent,  one  can  reassure 
such  girls  they  will  have  no  further  trouble  after  a  few 
months.  The  disease  with  which  we  are  more  apt  to 
associate  cessation  of  menstruation  is  tuberculosis,  but 
merely  because  tuberculosis  is  the  commonest  of  the 
serious,  long-standing  diseases  to  which  a  woman  can 
be  subject.  Anenija  (that  is,  the  real  thing  and  not  the 
word  which  is  often  falsely  used)  is  a  very  common 
cause  for  lack  of  menstruation,  but  one  can  say  with 
confidence  that  menstruation  will  come  back  as  soon 
as  the  anemia  is  overcome. 

I  have  already  spoken  of  pelvic  tumors  of  any  kind 
(or  tumors  elsewhere  which  are  malignant)  as  causes 
of  the  cessation  of  menstruation. 

There  never  should  be  any  direct  treatment,  any 
pelvic  treatment  for  a  cessation  of  menstruation. 
There  are  two  reasons  why  I  put  that  so  dogmatically. 
In  the  first  place,  it  never  does  any  good.  If  we  are  to 
restore  menstruation,  it  must  be  by  building  up  the 
general  health  and  stopping  the  cause.  Beyond  that 
the  attempt  to  restore  menstruation  is  pretty  sure  to 
get  mixed  up  with  the  attempt  to  perform  abortion  — 
with  the  attempt  to  kill  the  fetus  when  menstruation 
has  stopped  because  of  pregnancy.  Any  local  treat- 
ment of  the  uterus  when  menstruation  has  stopped 
because  of  pregnancy  is  likely  to  result  in  the  death  of 
the  fetus.  Girls  who  know  very  well  that  they  are 
pregnant  every  now  and  then  will  come  to  a  physician 

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and  ask  for  some  local  treatment  in  order  to  restore  the 
menses,  and  now  and  then  the  physician  is  unwise 
enough  or  wily  enough  to  do  this.  No  physician  likes 
to  be  called  an  abortionist,  but  a  good  many  physi- 
cians make  their  living  that  way.  The  trade  is  an 
enormously  profitable  and  thriving  trade.  There  are 
places  in  Boston  perfectly  well  known  to  the  police, 
places  called  hospitals,  where  nothing  else  is  done,  and 
where  with  the  aid  of  lawyers,  it  has  been  so  arranged 
that  no  evidence  of  crime  can  be  secured,  so  that 
nobody  can  be  convicted  of  anything.  It  is  a  crime 
which,  so  far  as  we  know  at  the  present  time,  cannot  be 
stopped.  It  will  go  on  so  long  as  people  desire  that  it 
shall.  No  abortionist  will  ever  admit  such  a  thing,  but 
among  physicians  it  is  generally-  pretty  well  known 
who's  who  in  this  matter,  and  it  is  one  of  the  things 
which  the  public  opinion  of  physicians  never  defends, 
—  I  mean  the  practice  of  the  abortionist  who  does  it 
as  a  regular  business. 

Now  the  question  of  when  an  abortion  can  be  per- 
formed because  of  serious  disease  in  the  mother,  —  not 
because  the  mother  does  not  want  the  child,  —  the 
question  of  producing  abortion  for  the  health  of  the 
mother,  is  one  on  which  the  Roman  Catholic  Church 
has  taken  a  perfectly  clear  and  definite  stand,  and  on 
which  the  rest  of  the  world  has  never  taken  any.  The 
Roman  Catholic  Church  has  held  that  no  matter  what 
ails  the  mother,  and  no  matter  if  you  are  perfectly 
sure  that  the  mother  may  die,  no  interference  with 

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DISEASES   OF   THE    GENERATIVE    ORGANS 

the  pregnancy  can  be  attempted.  It  perfectly  clearly 
faces  the  question  of  the  death  of  the  mother,  and  no 
exception  is  allowed.  This  has  all  the  advantages  of 
perfect  clearness  and  definiteness.  If  a  Roman  Cath- 
olic physician  did  such  a  thing,  he  would  be  going  con- 
trary to  all  the  canons  of  his  Church,  and  I  have  never 
known  a  Roman  Catholic  physician  to  do  it;  I  have 
known  one  to  tell  his  patient  to  go  to  a  Protestant 
physician.  With  Protestants  it  has  to  be  a  matter  of 
trying  to  see  what  we  think  is  right,  and,  as  I  say,  there 
is  a  hopeless  division  of  opinion  on  this  subject.  The 
vast  majority,  however,  of  Protestant  physicians  and 
of  Protestant  patients  hold  that  the  life  of  the  mother 
is  more  important  than  the  life  of  a  single  child,  and 
that  the  child  may  well  be  sacrificed  if  that  alternative 
is  unhappily  presented.  Under  these  conditions  a 
physician  will  always  talk  it  over  in  the  most  public 
way,  in  order  that  the  distinction  from  criminal  abor- 
tion may  be  clearly  made.  By  decent  physicians  the 
bringing  about  of  a  miscarriage  is  done  only  for  the 
health  of  the  mother,  and  only  with  the  fullest  under- 
standing and  publicity  by  every  one  concerned. 

As  it  is  against  the  law  to  convey  to  any  one  in  this 
State  information  as  to  how  this  can  be  done,  I  do  not 
propose  to  convey  this  information  here.  Probably 
most  people  already  have  this  information  or  can  get 
it.  I  do  not  myself  think  that  law  ought  to  be 
violated. 

Abortion  is  sometimes  a  very  serious  matter  for  the 

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mother  because  of  sepsis  —  blood  poisoning  —  which 
takes  place  at  the  time.  These  things  are  not  ordi- 
narily heard  of  unless  they  get  into  the  newspapers,  but 
once  in  so  often  the  uterus  is  poisoned,  cocci  are  intro- 
duced into  the  uterus  in  the  attempts  to  produce  abor- 
tion, and  puerperal  sepsis,  often  fatal,  occurs.  If  the 
trouble  is  recognized  early  the  cleaning  out  of  the 
uterus,  the  thorough  removal  of  what  is  left  behind 
after  the  abortion,  is  occasionally  valuable  and  may 
save  life. 

Questions  and  Answers 

Q.  What  about  misplacements  of  the  uterus? 

A.  I  have  said  that  the  uterus  had  no  one  normal  position, 
and  therefore  it  is  impossible  to  state  that  it  is  out  of  posi- 
tion. It  cannot  be  out  of  position  unless  there  is  a  single  cor- 
rect position. 

Q.  Why  do  some  patent  medicines  bring  relief? 

A.  In  the  first  place,  they  may  well  contain  powerful  and 
useful  drugs;  for  instance,  iodide  of  potash,  a  useful  drug  in 
syphilis.  But  a  much  commoner  and  more  important  reason 
for  the  seeming  usefulness  of  patent  medicines  is  that  most 
diseases  get  well  of  themselves,  and  if  we  happen  to  be  taking 
a  patent  medicine,  we  may  attribute  it  to  the  medicine.  I 
do  not  think  we  can  too  clearly  know  that  most  curable 
diseases  get  well  of  themselves. 

Diseases  of  the  male  generative  organs.  On  the  whole, 
male  genital  diseases  are  less  frequent  and  less  seri- 
ous to  the  individual  than  are  those  of  women. 

Of  course  the  commonest  disease  is  gonorrhea. 
Gonorrhea  in  men  attacks  chiefly  the  urethra,  the  tube 

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DISEASES  OF  THE    GENERATIVE   ORGANS 

leading  from  the  bladder  to  the  external  world.  When 
we  say  that  a  man  has  gonorrhea  and  say  nothing 
more,  we  ordinarily  mean  that  he  has  gonorrheal 
urethritisj  or  inflammation  of  the  urethra.  While  gonor- 
rhea may  be  innocently  acquired  by  little  girls,  I 
think  it  is  safe  to  say  that  it  is  never  so  acquired  by 
males  at  any  age.  There  are  a  good  many  tales  of  men 
who  have  picked  it  up  from  water-closet  seats,  towels, 
etc.  I  have  not  the  slightest  belief  in  them.  I  believe 
it  is  acquired  in  one  way  only  by  men  or  by  boys. 
Morally,  then,  it  is  quite  a  different  matter  from 
gonorrhea  in  little  girls. 

In  men  it  often  gets  well  without  treatment.  For 
purposes  of  public  health  and  to  promote  fear  we 
often  describe  the  consequences  of  gonorrhea  as  if  they 
were  always  as  severe  as  they  not  infrequently  are. 
But  it  has  to  be  recognized  that  the  majority  of  all 
cases  of  gonorrhea  get  well  without  any  serious  incon- 
venience to  the  man  himself ;  the  serious  inconveniences 
of  the  disease  are  to  other  people.  It  is  for  this  reason 
that  the  false  belief  is  prevalent  that  gonorrhea  is  an 
affair  of  no  great  importance.  So  far  as  the  selfish  in- 
dividual is  concerned,  it  is  often  not  of  great  impor- 
tance; it  may  not  even  lay  him  up  at  all.  If  it  remains 
confined  to  the  urethra,  it  causes  burning  and  fre- 
quency of  micturition  and  a  discharge  of  pus,  and 
nothing  else.  But  it  often  does  the  same  thing  to  the 
urethra  that  it  does  to  the  woman  in  the  Fallopian 
tube,  namely,  closing  that  tube,  partially  or  totally,  so 

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as  to  produce  what  we  call  stricture.  This  is  one  of  the 
serious  results  of  gonorrhea  in  men.  Often  it  is  slight 
in  degree,  merely  narrowing  the  tube  without  obstruct- 
ing it,  but  it  may  suddenly  shut  down  making  an  ab- 
solute obstruction,  so  that  the  urine  cannot  pass  at 
all.  Then  the  patient  has  what  is  called  acute  reten- 
tion of  urine ,  which  is  especially  apt  to  happen  in  cold 
weather,  and  is  very  often  due  to  this  cause.  There  is 
another  cause  (prostatic  obstruction)  of  which  I  will 
speak  later. 

Gonorrhea  may  go  beyond  the  urethra  into  the  blad- 
der, causing  cystitis,  as  I  have  already  said  in  relation 
to  the  same  disease  of  women.  That  is  seldom  serious 
in  men.  Its  most  frequent  serious  effect,  next  to  the 
production  of  stricture,  is  due  to  its  travelling  up  the 
tube  which  leads  from  the  urethra  to  the  testicle  and 
affecting  the  epididymis,  the  upper  portion  of  the 
testicle.  This  trouble,  while  in  itself  usually  not  very 
painful  or  very  serious,  goes  along  with  the  closure  of 
the  tube  through  which  the  spermatozoa  come.  The 
spermatozoa  cannot  then  get  from  the  testicle  to  the 
urethra  and  so  cannot  form  part  of  a  new  life.  Thus 
gonorrhea  often  causes  sterility.  It  is  in  fact  the  only 
common  cause  of  sterility  in  the  male. 

Gonorrhea  in  the  male  seldom  travels  any  farther;  it 
seldom  travels  up  to  the  kidney,  very  seldom  gets  to 
any  other  part  of  the  genital  system  except  the  pros- 
tate. The  prostate  gland,  which  encircles  the  urethra 
just  as  it  leaves  the  bladder,  may  become  infected,  and 

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DISEASES  OF  THE    GENERATIVE    ORGANS 

acute  inflammation,  or  prostatitis,  with  or  without 
abscess,  may  result. 

Either  in  men  or  in  women  gonorrhea  may  jump  to   I 
the  joints,  giving  gonorrheal  " rheumatism"  as  it  used   I 
to  be  called,  as  we  say  now,  gonorrheal  arthritis.  This  is  \ 
especially  apt  to  stay  in  one  joint  or  in  one  or  two,  as 
contrasted  with  true  rheumatism  which  affects  many 
at  a  time.  A  long-standing  inflammation  of  one  joint, 
if  we  can  exclude  tuberculosis,  is  most  apt  to  be  due 
to  gonorrhea.1 

I  have  said  that  in  the  vast  majority  of  cases  this 
disease  causes  the  man  no  considerable  inconvenience ; 
he  goes  about,  and  soon  thinks  that  he  is  wholly  well. 
But  the  most  terrible  thing  about  the  disease  in  its 
effects  on  the  human  race  is  its  tendency  to  stay  hidden 
and  painless  in  the  deeper  portions  of  the  urethra, 
whence  it  can  spring  up  again  and  affect  innocent 
wives.  The  man  thinks  he  is  cured  of  gonorrhea,  but 
it  takes  a  great  deal  of  investigation  by  an  expert 
physician  to  be  sure.  This  is  of  immense  importance, 
as  I  see  it,  to  every  woman  in  relation  to  the  question 
of  marriage.  A  certain  percentage  of  men,  no  human 
being  knows  what,  —  somewhere  in  the  vicinity  of  f^ 
thirty  per  cent  probably,  —  are  infected  with  gonor- 
rhea before  marriage.  They  usually  believe  that  they 
are  over  it.  No  woman  should  marry  such  a  man  with- 
out knowing  that  he  has  got  over  it  —  and  that  means 
an  investigation,  not  by  any  physician,  but  by  a  phy- 

1  See  p.  326. 

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sician  especially  trained  for  this  particular  thing,  a 
specialist  in  genito-urinary  diseases.  Such  an  investi- 
gator is  competent  to  tell  a  man  once  for  all  whether 
he  is  over  his  trouble  or  not.  I  think  all  of  us  ought  to 
do  what  we  can  to  spread  this  knowledge  and  to  make 
people  take  these  precautions.  Such  precautions  are 
certainly  taken  far  more  frequently  now  than  a  few 
years  ago.  A  good  many  men  have  begun  to  have 
some  conscience  on  this  subject,  because  for  the  first 
time  they  have  some  knowledge  about  it. 

Conor  rheal  ophthalmia,  the  extension  of  gonorrhea  to 
the  eye,  occurs  at  the  moment  of  birth,  as  the  child  is 
passing  out  of  the  mother's  body  —  infection  of  the 
child's  eye  by  the  micrococcus  of  gonorrhea.  Probably 
owing  to  the  campaigns  against  it  of  late  years,  the 
amount  of  blindness  resulting  from  this  cause  has  been 
very  much  decreased.  It  never  should  be  a  cause  of 
blindness,  because  we  can  very  easily  prevent  it  or 
stop  its  effects  upon  the  baby's  eyes.  Proper  obstet- 
rics and  the  putting  into  every  newborn  baby's  eyes 
of  a  proper  antiseptic,  will  stop  the  disease  in  every 
single  case.  Later,  if  the  disease  has  taken  hold  of  the 
baby's  eyes,  vigorous  treatment  in  a  hospital  will  cure 
a  great  many  more  who  otherwise  would  go  on  to  par- 
tial or  total  blindness. 

Enormously  common  in  elderly  men  is  the  swellings 
of  the  prostate  gland,  which  is  at  the  outlet  of  the  ure- 
thra, so  that  slight  swelling,  if  permanent,  is  a  great 
bother  and  finally  a  danger  from  obstruction  to  the 

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DISEASES  OF  THE    GENERATIVE    ORGANS 

flow  of  urine.  The  prostate  gland  projects  like  a  rock 
in  the  current,  and  finally  blocks  the  current.  It  is  one 
of  the  burdens  to  which  men  are  subject,  one  of  the  few 
burdens  that  are  really  worse  than  those  that  women 
have  —  I  mean  one  of  the  few  that  tend.to  even  up  the 
balance.  What  proportion  of  men  have  it  cannot  be 
accurately  stated;  a  large  proportion  of  men  have 
more  or  less  trouble  late  in  life. 

The  obstruction  first  results  in  a  stretching  and  a 
thickening  of  the  bladder,  and  then  in  back  pressure  of 
urine  up  the  ureters  upon  the  kidneys.  The  obstruc- 
tion produces  continuous  pressure  upon  the  kidneys 
and  by  that  the  kidneys  are  gradually  thinned  out  and 
their  function  diminished.  Aside  from  these  effects  on 
the  kidneys,  which  in  the  end  are  the  most  serious,  the 
bother  of  this  obstruction  is  very  great  in  that  it  en- 
tails very  frequent  micturition  day  and  night.  Finally 
a  great  many  men  get  so  that  they  cannot  pass  any 
urine  spontaneously;  they  have  to  draw  it  with  the  aid 
of  a  catheter,  and  have  come  to  what  is  sometimes 
called  "catheter  life."  When  a  man  gets  to  that  point 
he  has  to  draw  his  urine  altogether  with  the  catheter. 
Operations  are  done  nowadays  successfully  for  the 
relief  of  this  trouble,  provided  the  patient  is,  well 
enough  in  other  respects,  especially  with  respect  to  his 
heart,  to  stand  the  operation.  Occurring  as  it  does  in 
elderly  men  the  chances  are  considerable  that  the  heart 
has  been  weakened  by  the  arteriosclerotic  processes 
to  which  all  of  us  are  subject  as  we  get  older,  and  the 

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strain  of  the  operation  may  be  serious.  If  a  man's 
heart  is  in  good  shape  and  if  a  competent,  skilled  ex- 
pert is  obtainable,  the  operation  should  be  done  and  is 
done  an  enormous  number  of  times  with  very  great 
relief.  At  the  same  time  five  to  ten  per  cent  of  patients 
die  under  the  operation,  partly  because  it  is  not  skil- 
fully done,  but  more  often  because  the  condition  of 
the  heart  is  not  estimated  at  the  beginning. 

Another  condition  often  spoken  of  as  a  disease  of  the 
male  generative  organs  is  varicocele.  Anything  that 
has  the  word  cele  means  that  it  conceals  or  shuts  in 
something.  A  hematocele,  for  instance,  is  a  cyst  or  sac 
where  blood  is  shut  in.  A  varicocele  is  a  sac  in  which 
distended  veins  are  shut  in.  Varicocele  is  the  shutting- 
in  of  a  bunch  of  distended  veins  in  the  groin  and  near 
the  testicle.  I  want  to  emphasize  the  fact  that  varico- 
cele is  not  a  disease  at  all,  because  countless  unfortu- 
nate individuals  spend  their  money  and  risk  their 
health  in  unnecessary  operations  for  a  thing  that  is  not 
a  disease  and  is  merely  a  peculiarity  of  no  importance. 

Before  leaving  the  subject  of  the  genital  system  I 
want  to  say  a  few  words  on  a  matter  which  does  not 
strictly  belong  here,  —  the  much-disputed  subject  of 
birth-control.  In  the  first  place,  there  is  no  authorita- 
tive medical  opinion  on  that  subject.  It  is  not  pri- 
marily a  medical  question,  but  an  ethical  one.  Never- 
theless, the  doctor's  opinion  is  very  often  asked.  I  am 
not  giving,  therefore,  any  authoritative  medical  view 
—  I  am  simply  giving  my  view. 

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DISEASES  OF  THE    GENERATIVE    ORGANS 

By  birth-control  is  usually  meant  the  control  of  birth 
by  artificial  means;  that  is,  by  means  other  than  the 
remaining  apart  of  the  sexes.  I  am  opposed  to  birth- 
control  in  that  sense :  first,  because  it  is  contrary  to  law 
in  this  State.  Not  every  law  deserves  absolute  obedi- 
ence; some  laws  about  Sunday,  for  instance,  are  left 
on  the  statute  books  merely  from  carelessness.  But  if 
any  one  made  the  attempt  to  repeal  this  law  regarding 
birth-control,  I  do  not  think  they  would  get  thirty  per 
cent  of  votes.  It  is  a  law  which  public  opinion  sup- 
ports. Therefore,  if  we  violate  this  law,  we  are  violat- 
ing our  unspoken  oath  of  citizenship  —  the  oath  we 
never  took,  but  which  applies  to  us.  When  we  get 
beyond  legality  we  enter  a  field  where  there  are  count- 
less opposing  standards.  There  is  the  standard  of 
world-politics:  world-politicians  tell  us  that  we  must 
not  check  births,  because  we  need  more  citizens  to 
defend  the  state  against  attack.  Economists  of  the 
Malthusian  type  of  mind  tell  us:  "  You  can't  afford  so 
many  children,  and  so  they  should  not  be  born."  The 
eugenist  says:  "The  more  children  in  a  family  the 
weaker  the  children  are."  But  there  are  two  opinions 
on  this  —  the  better  opinion,  I  think  on  the  whole, 
opposing  the  belief  that  when  other  conditions  are  the 
same,  large  families  give  the  state  weaker  children 
than  small  families  do.  I  think  that  we  get  into  a  per- 
fectly hopeless  muddle  of  conflicting  standards  if  we 
take  any  other  than  the  religious  point  of  view  here. 
The  only  way  the  matter  can  be  settled  is  by  asking 

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what  is  the  best  for  the  human  spirit.  Anything  which 
is  so  contrary  to  nature  as  an  artificial  control  tends  to 
split  body  and  soul  apart,  and  to  make  a  great  and 
sacred  function  a  very  cheap  affair.  On  religious 
grounds,  then,  and  on  the  ground  of  obeying  the  laws, 
I  personally  am  wholly  opposed  to  the  artificial  con- 
trol of  births.  I  think  I  know  every  argument  that  has 
ever  been  brought  upon  the  other  side.  I  have  taken 
part  in  a  great  many  discussions  and  have  read  all  that 
I  could  find  in  favor  of  artificial  birth-control,  but  I 
think  it  is  not  convincing. 

Septic  Peritonitis.  From  time  to  time  peritonitis  has 
been  mentioned  in  these  pages  as  the  result  of  perfora- 
tion of  the  appendix,  the  gall-bladder,  the  stomach  or 
duodenum  (peptic  ulcer),  the  intestine  (typhoid  ulcer), 
or  the  Fallopian  tube  (salpingitis) .  If  the  perforation 
occurs  slowly  and  gradually,  adhesions  form  about  it 
and  wall  in  the  virulent  bacilli  so  that  they  cannot 
spread  through  the  peritoneal  cavity.  This  local  peri- 
tonitis is  usually  not  serious,  though  the  adhesions  may 
later  bother  the  adjacent  organs  in  their  work. 

But  if  perforation  occurs  rapidly  the  inflammation 
spreads  throughout  the  whole  abdomen,  producing 
general  peritonitis  and  paralysis  of  the  intestines.  This 
paralysis  allows  poisons  to  be  formed  and  absorbed  in 
the  intestines,  just  how  or  why  we  do  not  know.  These 
poisons  absorbed  into  the  blood  produce  death.  ' 

The  symptoms  of  general  peritonitis  are  tenderness 
and  rigidity  of  the  whole  belly  wall,  obstinate  constipa- 

216 


DISEASES    OF   THE    GENERATIVE    ORGANS 

tion,  fever,  vomiting,  rapid,  feeble  pulse,  and  often  hic- 
cup. Death  usually  follows  in  a  few  days,  but  repeated 
washing  of  the  stomach  (to  clear  out  poisons)  and  the 
constant  administration  of  water  by  the  rectum  so  as 
to  make  up  for  the  fluids  vomited  or  siphoned  out  of 
the  stomach,  may  save  life. 


CHAPTER   IX 

DISEASES   OF   THE   NERVOUS   SYSTEM 

THE  diseases  of  the  nervous  system  include  diseases  of 
the  brain,  diseases  of  the  spinal  cord,  diseases  of  the 
nerves  as  they  run  outside  the  spinal  cord  in  the  arms, 
legs,  and  body  —  what  we  call  the  "peripheral  nerves " 
-  "peripheral'*  meaning  at  the  surface  of  the  body. 
Nerve  disease  also  includes  a  good  many  diseases 
without  known  pathology.  When  we  do  not  know 
where  the  trouble  is  or  in  what  organ  it  resides,  we 
are  apt  to  suppose  that  it  is  connected  in  some  way 
with  the  nervous  system.  That  last  group  includes 
most  of  the  insanities  and  miscellaneous  other  disturb- 
ances involving  conspicuously  the  field  of  nervous 
action. 

I  shall  begin  with  the  disturbances  of  mental  life. 
These  belong  in  four  groups,  each  more  serious  than 
the  last  in  the  order  in  which  I  give  them.  The  first 
deviation  from  normal  might  be  called  "moods";  the 
second,  " psychoneuroses " ;  the  third,  "psychoses"; 
and  the  fourth,  "insanities." 

To  moods  which  I  do  not  suppose  we  can  say  are 
wholly  normal,  practically  the  whole  human  race  is 
subject.  There  are  very  few  people  who  can  say  they 
never  were  blue  in  their  lives,  very  few  who  can  say 
they  never  lost  their  tempers.  At  the  same  time,  if 

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DISEASES  OF  THE  NERVOUS  SYSTEM 

those  moods  are  continued  and  intensified,  they  would 
merge  into  other  and  more  serious  groups.  Hence  they 
must  be  recognized  as  connecting  all  of  us  with  those 
more  serious  mental  diseases  and  making  it  compara- 
tively easy  for  us  to  understand  them.  A  person  of 
very  intense  passions  may  kill,  for  instance,  in  a  fit  of 
passion,  and  then  the  question  always  arises  as  to 
whether  he  was  sane  or  not.  I  think  it  is  wholly  wrong 
to  assume  that  merely  because  a  person  does  some 
fearful  act,  like  homicide,  therefore  he  is  insane.  I 
think  we  all  have  homicidal  moments.  Moods,  then, 
are  not  generally  taken  as  a  part  of  a  disease,  unless 
habitual  and  very  extreme  in  degree. 

Psychoneuroses,  the  next  group,  may  also  merge  in- 
distinguishably  into  health.  Almost  any  one,  if  run 
down  as  a  result  of  any  disease  or  of  no  disease,  may  be 
psychoneurotic,  or,  as  we  used  to  say,  neurasthenic, 
for  a  few  days  or  weeks.  Bring  pressure  enough,  pres- 
sure of  starvation,  pressure  of  terror,  of  worry,  of  dis- 
ease, and  almost  any  one  will  be  driven  beyond  the 
normal  to  what  we  may  call  a  psychoneurotic  state. 
It  is  more  than  a  mood  because  it  is  more  permanent. 
There  is  nothing  that  I  resent  more  than  the  attempt 
to  arrange  the  whole  human  race  into  two  classes,  psy- 
choneurotics  and  others.  We  may  some  of  us  be  fortu- 
nate enough  to  escape  such  states  for  a  considerable 
portion  of  our  lives,  but  we  have  no  reason  to  look 
down  upon  anybody  else  who  does  not  so  escape. 
Psychoneurotic  states  we  all  have  off  and  on,  but  when 

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such  states  are  permanent  it  is  a  different  matter.  That  is 
disease  and  we  call  it  a  psychoneurosis. 

The  psychoneuroses,  in  my  opinion,  are  always  in- 
herited, congenital  states,  something  more  than  a 
symptomatic  and  temporary  disturbance.  When  with- 
out any  temporary  physical  cause  a  person  has  the 
symptoms  which  will  be  described  presently,  then  I  be- 
lieve that  a  careful  history  will  always  show  that  the 
trouble  goes  back  to  childhood,  and  that  there  have 
been  traces  in  that  person  from  the  earliest  time,  be- 
cause the  tendency  was  in  his  blood.  This  does  not 
mean  that  a  psychoneurosis  is  not  curable,  but  that 
the  patient  will  have  to  fight  it,  as  he  might  have  to 
fight  tuberculosis,  as  long  as  he  lives.  Psychoneurotics 
are  curable,  but  eternal  vigilance  is  the  price  of  liberty 
from  psychoneurosis  as  from  tuberculosis. 

I  am  entirely  convinced  that  hard  work,  whether 
mental  or  physical,  never  produces  a  psychoneurosis. 
It  may  make  a  person  run  down,  feel  poorly,  and  be- 
have queerly  for  a  short  number  of  weeks,  but  there  is 
no  commoner  fallacy  than  that  overwork  either  of 
mind  or  body  produces  a  psychoneurosis. 

(i)  In  the  first  place,  a  psychoneurosis  means  over- 
sensitiveness,  in  every  sense  —  over  sensitiveness  to 
noise,  to  smell,  to  having  the  feelings  hurt,  to  changes 
in  surroundings,  to  reproof.  Perhaps  it  is  only  the 
same  thing  to  say  that  in  the  psychoneurotic  emotion 
is  not  controlled  to  the  extent  that  it  is  in  other  people. 
Emotion  dominates. 

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DISEASES  OF  THE  NERVOUS  SYSTEM 

(2)  Self-centredness.  Partly  because  these  troubles 
last  so  long,  it  is  almost  inevitable,  as  in  some  organic 
diseases  also,  that  a  person  should  become  more  or  less 
self-centred.  A  person  with  hip  disease  or  cancer  may 
get  self-centred  because  through  isolation  and  idleness 
he  has  been  driven  in  upon  himself.  The  psychoneu- 
rotic  has  merely  the  self-centredness  of  the  average 
chronic  invalid.  There  are  some  chronic  invalids  and 
also  some  psychoneurotics  who  are  not  self-centred, 
but  it  always  seems  to  me  heroic  when  they  succeed  in 
maintaining  themselves  free  from  self-centredness. 

We  can  divide  the  psychoneuroses  into  five  groups: 
(i)  the  neurasthenic  type,  (2)  the  hysteric  type,  (3) 
the  psychasthenic  type,  (4)  traumatic  psychoses,  and 
(5)  the  visceral  psychoses. 

There  are  no  hard-and-fast  lines  between  these 
types.  They  run  into  each  other.  Any  patient  may 
have  three  or  four  of  them  in  a  lifetime,  one  shifting  to 
another  according  to  circumstances.  Nevertheless, 
they  are  worth  distinguishing. 

The  neurasthenic  type  is  so  named  from  words  which 
mean  weakness  of  the  nerves.  The  nerves  are  really 
never  weak;  they  are  merely  telegraph  wires  which 
transmit  messages.  But  we  use  the  term  for  patients 
in  whom  fatiguability,  pathological  fatiguability,  is  the 
most  prominent  symptom.  We  distinguish  this  dis- 
ease from  ordinary  fatigue  —  fatigue  with  adequate 
cause.  As  a  rule  the  neurasthenic  has  not  been  doing 
hard  work  either  of  mind  or  body  for  years.  It  has 

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often  been  said,  I  think  truly,  that  these  persons  were 
born  tired  and  have  been  getting  more  so  ever  since. 
If  that  is  said  without  any  sense  of  superiority  or  of 
cynicism,  I  think  it  is  true.  The  only  thing  which  will 
rest  them  is  work.  One  neurasthenic  has  a  weak  back 
and  cannot  use  his  muscles;  he  is  tremendously  easily 
fatigued  in  this  respect.  Another  cannot  hold  his 
attention  or  cannot  carry  on  a  conversation. 

Characteristic,  then,  of  this  whole  type  is  weakness, 
weakness  of  every  type.  Of  course  the  diagnosis  can 
never  be  established  save  by  the  most  rigid  physical 
examination,  excluding  all  known  physical  causes.  A 
man  with  heart  disease,  tuberculosis,  peritonitis,  can- 
cer, arteriosclerosis,  brain  syphilis,  may  present  the 
same  symptoms  as  the  neurasthenic,  and  yet  physical 
examination  may  show  that  he  is  as  far  as  possible  from 
being  a  neurasthenic  patient.  We  then  begin  by  ex- 
cluding, through  a  prolonged,  searching  examination, 
all  discoverable  organic  disease.  It  is  still  open  to 
any  one  to  say,  "There  is  a  disease  there,  but  you  have 
not  yet  found  it."  But  many  post-mortems  have  been 
done  on  such  people  without  anything  being  found. 

The  hysteric  type,  I  think,  is  the  rarest  of  the  five.  It 
is  a  long  time  since  I  have  seen  a  case  of  pure  hysteria, 
the  type  in  which  one  tends  to  have  seizures,  parox- 
ysms, fits  of  one  or  another  kind.  In  the  novels  this  is 
shown  by  fits  of  laughing  and  crying.  In  real  life 
laughing  and  crying  fits  are  not  nearly  so  common  as  a 
sudden  unconsciousness  under  conditions^which  soon 

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DISEASES  OF  THE   NERVOUS  SYSTEM 

convince  us  that  we  are  not  dealing  with  a  true  faint.  I 
was  passing  an  apartment  house  one  day  when  some 
one  opened  a  window  and  called,  "  Come  in,  quick! "  I 
found  in  the  lobby  a  very  large,  agitated  hotel  manager 
and  a  lady  whom  I  knew.  The  patient  was  lying  on  the 
lobby  floor,  and  the  manager  was  very  indignant  be- 
cause she  was  messing  up  his  hotel.  I  felt  the  patient's 
pulse  and  found  it  going  steadily  and  strongly ;  hence 
there  was  obviously  no  immediate  emergency.  Then  I 
looked  at  her  face  and  found  that  her  eyelids  were 
trembling  and  twitching.  You  can  say,  I  think,  with- 
out fear  of  contradiction,  people  never  have  that  when 
they  are  in  a  fainting  fit.  Fainting  means  absolute 
relaxation.  The  fact  that  the  eyelids  were  trembling 
made  pretty  clear  to  me  that  it  was  not  a  faint.  Again, 
when  I  took  hold  of  the  patient's  pulse  the  hand  of  the 
patient  came  over  and  spasmodically  gripped  my  little 
finger.  Then  I  was  pretty  sure  of  the  diagnosis,  and  to 
test  it  still  further  I  applied  a  fitting  stimulus,  such  as 
will  bring  an  hysteric  out  of  her  fit.  In  old  times  throw- 
ing a  bucket  of  water  was  the  accepted  treatment. 
This  seems  rather  unnecessarily  cruel.  Modern  meth- 
ods are  kinder  and  quicker.  I  turned  to  the  hotel  man- 
ager and  said,  "Will  you  please  send  for  the  Boston 
City  Hospital  Ambulance?"  Then  the  patient  at  once 
sat  up  and  said  she  could  n't  stand  going  to  a  hospital* 
After  reading  a  story  like  that  it  is  very  hard  for  us 
to  avoid  the  impression  that  the  woman  was  simply 
shamming.  But,  in  truth,  she  was  not  enjoying  herself  at 

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all.  It  was  not "  pure  cussedness  "  —  I  beg  you  to  take 
it  on  authority  that  it  was  not  so.  A  person  does  not 
do  this  sort  of  thing  for  fun,  and  yet  he  has  no  acute 
organic  disease  and  can  be  roused  into  the  full  posses- 
sion of  his  faculties  by  proper  stimulus.  I  believe  that 
the  will  is  not  in  a  condition  to  be  appealed  to ;  the  will 
is  in  abeyance.  We  can  understand  it  by  adopting 
Janet's  theory  of  these  states,  which  is  that  they  are  in 
fact  a  strange  sort  of  f or getf nines s.  The  hysterical  per- 
son exemplifies  a  type  of  very  extraordinary  absence  of 
mind.  We  can  all  do  very  queer  things  when  we  are 
forgetful.^ You  are  facing  an  audience  and  suddenly 
you  become  stage-struck  and  cannot  remember  in  the 
least  what  you  meant  to  say,  what  you  are  there  for, 
nor  even  what  your  name  is.  You  are  not  organically 
diseased,  not  paralyzed,  neither  are  you  doing  this 
thing  for  the  fun  of  it,  but  you  cannot  get  out  of  the 
state  until  you  somehow  get  the  proper  stimulus.  In 
my  case  the  proper  stimulus  is  my  notes.  If  I  find  my- 
self in  absolute  forgetfulness,  my  mind  a  blank,  I  apply 
the  proper  stimulus,  my  notes.  No  exercise  of  my  will 
can  do  it  —  I  am  only  able  to  hitch  myself  to  the 
proper  stimulus. 

The  hysterical  person,  then,  suffers  from  an  extraor- 
dinary kind  of  forgetfulness.  He  may  forget,  for  ex- 
ample, how  to  move  his  right  arm.  How  do  you  move 
your  right  arm?  You  cannot  move  your  ears ;  some  can. 
You  have  forgotten  how  to  move  your  ears.  Animals 
all  know  how;  but  we  have  lost  that  portion  of  mem- 

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DISEASES  OF  THE  NERVOUS  SYSTEM 

ory.  We  have  perfectly  proper  muscles  to  pull  the 
ears  as  a  horse  can,  in  three  directions.  The  hysterical 
patient  for  the  time  has  forgotten  how  to  move  his 
muscles.  He  can  be  reminded,  however,  by  shocks 
which  "bring  him  to  himself,"  as  we  say,  by  healing 
this  split  in  consciousness  which  is  forgetting.  A  pecu- 
liar type  of  hysterical  psychoneurosis  is  the  exagger- 
ation of  our  ordinary  multiple  personalities.  Person- 
alities can  get  split  up  into  pieces;  it  happens  to  all. 
We  all  have  a  tendency  to  be  multiple  personalities, 
and  the  more  attention  we  pay  to  it  the  more  we  have. 
A  person  talking  French,  for  example,  is  quite  a  differ- 
ent person  from  the  same  man  talking  English.  It  is 
not  merely  that  he  is  using  different  words;  a  wholly 
different  side  of  his  soul  comes  up.  A  person  playing 
baseball  is  a  totally  different  person  from  his  ordinary 
business  self,  and  a  person  practising  medicine  can  for 
a  time  forget  his  duties  and  obligations  in  other  direc- 
tions. There  are  half  a  dozen  people  within  every  tene- 
ment of  clay,  and  one  should  not  get  excited  over  these 
cases  which  we  read  of  in  textbooks.  The  most  impor- 
tant case  of  the  kind  was  Dr.  Prince's  "The  Misses 
Beauchamp."  1  The  Misses  Beauchamp  are  one  lady. 
By  paying  a  great  deal  of  scientific  attention  to  the 
moods  of  this  lady,  Dr.  Morton  Prince  convinced  him- 
self that  she  was  several  people.  Dr.  Janet  when  he 
was  here  told  me  that  he  thought  at  that  time  she  had 

1  Dr.  Morton  Prince,  The  Development  and  Genealogy  of  the  Misses 
Beauchamp.    London,  1901. 

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five  personalities,  and  added,  "She  will  have  more  if 
Dr.  Prince  keeps  on  studying  her."  We  should  not 
take  these  things  too  seriously.  It  is  perfectly  possible 
to  split  one's  self  up  into  as  many  personalities  as  we 
have  time  to,  and  attention  intensifies  the  unfortunate 
separation. 

Hysterical  tumor  is  a  very  bad  term.  It  means  a 
tumor  that  the  doctor  has  not  found  any  cause  for,  and 
it  disappears  about  the  time  another  doctor  gets  there. 
It  is  usually  an  accumulation  of  gas  in  the  stomach  or 
intestine  which  is  so  tense  that  it  appears  like  a  solid 
body,  and  yet  under  ether  relaxes.  It  is  better  called  a 
"phantom  tumor." 

Questions  and  Answers 

Q.  What  is  the  cause  of  hysterical  fainting? 

A.  The  cause  of  the  fainting  is  that  the  person  forgets 
how  to  exercise  that  control  of  himself  which  keeps  him  in 
touch  with  reality.  People  in  a  brown  study  may  entirely 
forget  the  outer  world ;  carry  it  a  little  farther  and  you  have 
a  person  in  unconsciousness,  merely  by  pushing  a  little  far- 
ther what  happens  to  all  of  us.  None  of  these  things  are  so 
extraordinary  as  they  seem. 

Q.  Is  the  blindness  that  so  many  of  the  soldiers  are  suffer- 
ing from  hysterical? 

A.  I  suppose  so.  From  what  I  have  been  told  by  army 
physicians,  it  seems  to  me  that  that  belongs  in  this  group. 

It  is  an  enormous  subject,  this  subject  of  hysteria,  but  for 
us  important  only  to  this  extent.  The  thing  is  not  "  pure  cus- 
sedness  "  and  not  organic  disease,  but  belongs  in  an  extraor- 
dinary limbo  between  those  two.  It  is  a  queer  kind  of  for- 
getfulness  or  mental  split  of  which  every  one  of  us  has  had  a 
mild  example  whenever  we  have  been  stage-struck  or  shy. 

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DISEASES  OF  THE   NERVOUS  SYSTEM 

Psychasthenia  refers  to  states  in  which  there  are  no 
special  weaknesses  of  muscles,  no  special  fatiguability, 
no  special  forgetfulness,  but  in  which  the  whole  trouble 
works  itself  out  in  the  field  of  mental  life.  The  word 
means  weakness  of  the  soul  —  weakness  of  the  mental 
life;  it  is  there  rather  than  in  the  muscles  or  internal 
organs  that  the  trouble  shows  itself.  The  typical 
psychasthenic  is  the  person  who  is  dogged  by  fears  of 
one  kind  or  another.  When  mental  life  is  below  its 
normal  level  of  heat  and  energy,  fears  break  upon  one. 
It  is  weakness,  then,  that  leads  to  fears.  Perhaps  an 
autobiographical  example  will  bring  this  home.  I  was 
brought  up  in  the  country  before  the  age  of  telephones, 
and  I  used  to  be  sent  after  dark  on  errands  to  one  of 
my  cousins'  houses  about  a  mile  off.  Of  course,  like 
any  child,  I  was  not  going  to  acknowledge  that  I  was 
afraid  of  the  dark;  nevertheless,  these  were  occasions 
of  terror.  But  I  noticed  that  there  were  certain  times 
when  my  fear  of  the  dark  did  not  bother  me.  If  just 
before  I  started  on  my  errand  I  had  been  playing  the 
violin  or  doing  anything  pleasant,  I  could  carry  the 
heat  and  energy  of  that  music  along  with  me  so  that  I 
had  not  time  to  be  afraid.  My  mind  was  so  active  that 
terror  could  not  creep  in.  It  was  when  energy  died  out 
and  I  was  tired  and  cold  that  the  fear  could  creep  in. 
Keeping  the  mind  so  full  of  active  ideas  that  fear  has 
no  time  to  get  in  is  the  way  to  keep  it  out. 

The  psychasthenic  is  tortured,  not  only  by  fears, 
but  by  a  sense  of  personal  inefficiency.  When  a  person 

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who  certainly  can  do  a  thing  is  suddenly,  or  not  so  sud- 
denly, convinced  that  he  can't,  and  gets  so  that  he 
gives  up  doing  things  which  he  perfectly  well  can  do, 
he  belongs  in  this  same  field.  Making  up  his  mind  is 
sometimes  one  of  the  things  which  seems  impossible 
to  him.  He  is  abnormally  diffident  and  self-reproach- 
ful. 

The  traumatic  type  of  psychoneurosis  is  of  great  im- 
portance to  us  in  relation  to  working  men's  compensa- 
tion, or  compensation  for  any  class  of  persons.  These 
psychoneuroses  used  to  be  spoken  of  as  railway  spine, 
because  a  great  many  people  after  a  railway  acci- 
dent get  troubles  which  are  referred  to  the  spine.  It 
could  perfectly  well  be  "railway  head"  or  "railway 
stomach";  the  only  point  is  that  it  has  some  relation 
to  an  accident.  Rigid  physical  examination  shows 
that  there  is  nothing  the  matter.  The  person  genuinely 
believes  that  there  is  something  the  matter,  and  cannot 
get  rid  of  that  belief.  Unfortunately  the  whole  issue  is 
clouded  by  the  effect  of  money  and  litigation.  The 
lawyers  on  the  side  of  the  company  are,  I  think,  gen- 
uinely convinced  that  the  patient  is  merely  shamming 
and  that  he  will  continue  to  suffer  until  he  gets  money 
from  the  railway.  Then  he  will  cease  to  suffer;  it  is  an 
extraordinary  coincidence.  We  need  not  always  inter- 
pret this  in  a  cynical  sense.  The  effect  of  the  excite- 
ment and  anticipation  connected  with  the  lawsuit,  the 
hopes  and  apprehensions,  are  sometimes  enough  to  up- 
set any  one  who  is  congenitally  oversensitive  or  psycho- 

228 


DISEASES  OF  THE   NERVOUS  SYSTEM 

neurotic.  When  the  suit  is  settled,  even  if  it  is  settled 
against  him,  he  is  better. 

Recently  I  saw  at  the  Massachusetts  General  Hos- 
pital a  most  extraordinary  example  of  what  I  am  en- 
tirely convinced  is  a  traumatic  neurosis.  A  man  in  the 
course  of  his  work  got  some  injury  to  his  wrist  —  I  did 
not  learn  exactly  what.  Some  time  afterwards  one  of  his 
fingers  was  found  to  be  shut  tightly  into  his  palm.  He 
is  now  getting  damages  on  the  basis  that  the  injury 
caused  the  finger  condition.  It  is  almost  impossible, 
for  anatomical  reasons,  to  see  how  this  finger  alone 
could  be  affected  in  this  way.  However,  when  we  gave 
him  ether  the  whole  thing  came  out  straight,  which 
proved,  I  think,  that  it  was  hysterical  or  a  traumatic 
neurosis.  Yet  he  is  getting  large  amounts  in  damages 
because  there  is  supposed  to  be  disease  in  his  hand. 
The  finger  contracted  again  when  he  came  out  of  the 
ether.  The  lawyer  for  the  defence  will  say  it  is  all  sham- 
ming. I  do  not  think  so.  I  believe  that  the  patient 
really  thinks  he  cannot  do  anything  with  that  finger  and 
has  formed  the  habit  of  keeping  it  shut  in  on  his  palm. 

Visceral  psychoneuroses  are  those  which  refer  to  one 
or  other  of  the  internal  organs.  The  gastric  neuroses, 
the  cardiac  and  the  pelvic  and  so  on,  mean  that  a 
person  somehow  or  other  applies  all  his  characteristic 
fears  and  emotions  to  one  organ  —  he  comes  to  believe 
that  his  stomach,  for  example,  is  incurably  diseased, 
and  then  he  cannot  get  his  mind  off  that  stomach.  I 
have  often  spoken  of  these  things  as  a  dislocation  of 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

consciousness.  Consciousness  is  meant  to  go  on  with- 
out any  attention  upon  the  functions  of  our  bodies. 
Our  stomachs  and  our  hearts  and  our  lungs  are  meant 
to  do  their  work  without  any  help,  and  to  become 
aware  that  we  have  a  stomach  or  a  heart  is  the  great- 
est misfortune.  As  a  bone  becomes  dislocated,  so  con- 
sciousness gets  out  of  place  and  it  is  very  hard  to  get  it 
back.  Some  temporary  upset  calls  a  person's  attention 
to  his  stomach;  he  gets  the  idea,  perhaps  from  some- 
thing that  the  doctor  has  not  said,  that  he  is  very  much 
alarmed  about  the  stomach.  Then  the  patient  broods 
over  the  fear  that  the  doctor  does  not  dare  to  tell  him 
how  bad  it  is.  Out  of  that  comes  a  disease,  a  habit  of 
mind,  which  will  render  a  person  as  thorough  a  sufferer 
as  any  you  can  see.  In  diagnosis  we  must  first  demon- 
strate by  the  most  thorough  physicial  examination 
that  there  is  no  organic  trouble  anywhere  and  then 
begin  a  course  of  training  directed  to  lead  the  patient's 
mind  in  other  directions. 

These  visceral  psychoneuroses  are  very  common, 
much  commoner  than  any  others  that  I  have  men- 
tioned. The  medical  profession  has  a  considerable  part 
in  forming  them.  We  doctors  sometimes  quite  unin- 
tentionally direct  the  patient's  attention  altogether 
too  much  upon  one  or  the  other  of  his  bodily  organs. 
All  hygiene  has  this  danger.  To  be  conscious  even  of 
our  health  is,  I  think,  a  diseased  state.  We  ought  to 
be  thinking  about  our  job  and  not  about  our  health  or 
our  diseases. 

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DISEASES  OF  THE  NERVOUS  SYSTEM 

Half  of  any  general  practitioner's  ordinary  work  is 
concerned  with  some  type  of  psychoneurosis ;  not 
half  that  the  neurologists  do,  but  half  that  all  of  the 
doctors  in  the  country  are  doing  to-day,  is  to  treat 
psychoneurotics.  That  is  important  in  many  ways.  It 
seems  to  me  most  important,  because  very  fe\£  of  the 
doctors  have  ever  been  trained  to  treat  a  psychoneu- 
rotic;  very  few  have  any  interest  in  it.  The  attitude  of 
many  a  doctor  is  expressed  in  his  desire  to  run  out  the 
side  door  when  one  of  these  patients  appears  at  the 
front.  He  hates  them,  but  cannot  afford  to  show.  it. 
Yet  nobody  will  help  this  type  of  patient  who  does  n't 
feel  a  very  keen  interest  in  him,  and  find  the  disease 
fascinating  as  a  study  of  character  only  slightly  re- 
moved from  what  every  one  of  us  has. 

It  has  often  been  said  that  this  disease  is  increasing, 
but  we  have  no  statistics  on  which  to  base  any  such 
statement. 

The  treatment  of  this  trouble  is  real  life.  In  one  way 
or  another  these  people  have  usually  been  shunted  off 
to  a  side  track,  partly  through  invalidism  and  lack  of 
contact  with  their  fellows,  and  partly  through  lack  of 
money.  Hence  the  treatment  is  reaj  life,  in  the  sense 
of  doing  whatever  one  can  to  get  the  person  back  into 
normal  relations  with  human  beings,  with  duty  and 
with  God,  which  keep  the  whole  of  us  going.  No  one 
can  realize  how  much  W  are  all  of  us  kept  not  only 
happy  but  healthy,  how  much  our  stomachs  and  hearts 
as  well  as  our  mental  life  are  kept  going,  by  the  normal 

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ties  to  the  world.  That  is  the  general  formula.  In 
every  case  there  are  a  hundred  different  things  to  be 
said,  but  I  have  said  most  of  what  I  mean  in  a  book 
called  "What  Men  Live  By."  To  help  a  psychoneu- 
rotic  we  attempt  to  bring  him,  in  whatever  degree  we 
can,  —  often  a  very  small  degree,  —  into  touch  with 
the  great  forces  by  which  well  people  keep  well.  Of 
course  this  means  that  I  am  entirely  opppsed  to  sana- 
torium treatment,  to  sending  people  abroad,  and  put- 
ting them  to  bed.  I  think  these  are  the  most  tragic 
mistakes  in  the  world.  "Rest'*  in  bed  may  have  a 
place  when  a  person  is  frantic  or  dazed,  but  only  until 
we  have  time  to  turn  round  and  see  what  is  the  next 
thing  to  do.  No  matter  how  weak  the  psychoneurotic 
is,  he  must  use  the  little  power  he  has  in  order  to  get 
more.  If  a  person  has  very  little  muscle  on  his  legs,  he 
must  exercise  that  little  in  order  to  get  more.  Patients 
often  say,  "  I  cannot  read  halfway  down  a  page  before 
my  attention  is  tired  and  I  forget  it  all."  I  always  urge 
such  people  to  go  on  reading,  and  lead  them  to  see  that 
only  in  this  way  can  they  gain  the  power  to  read  the 
page  and  then  to  read  more.  They  must  do  the  thing 
they  "cannot  do11  —  do  the  thing  they  are  afraid  to  do 
—  get  where  by  contact  with  other  people  they  forget 
themselves  and  find  the  normal  centre,  instead  of  the 
abnormal  centre,  for  life. 

I  have  talked  about  work,  but  I  do  not  think  any- 
body was  ever  cured  just  by  work.  They  must  play, 
too,  they  must  get  their  affections  straightened  out, 

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DISEASES  OF  THE  NERVOUS  SYSTEM 

and  find  "their  own  relations  to  God  before  they  are 
ever  proof  against  the  re-attacks  of  this  trouble. 

The  psychoses  are  the  next  most  serious  group  of  the 
mental  troubles.  By  far  the  commonest  of  them  is  the 
so-called  manic-depressive  psychosis.  Like  the  last  type, 
I  think  this  has  a  close  relation  to  heredity,  although 
we  know  very  little  about  it.  This  doesn't  mean  that 
it  comes  from  parents  who  had  just  the  same  trouble, 
but  that  there  is  some  definite  hereditary  taint  (al- 
coholism, insanity,  criminality,  phthisis)  to  be  found 
in  the  stock  of  the  vast  majority  of  patients.  The  word 
manic  means  excitement ;  it  does  not  mean  at  all  what 
we  think  of  when  we  think  of  the  traditional  maniac. 
Harvard  boys  after  a  successful  football  game  are  in 
the  typical  manic  state.  Excitement,  then,  is  one  half 
of  this  disease;  depression  in  the  ordinary  sense,  but 
intensified,  is  the  other  half. 

In  the  sharpest  possible  contrast  with  psychoneu- 
roses,  which  run  through  a  person's  life  until  he  comes 
to  terms  with  them,  the  manic  depressive  psychosis 
is  a  self-limited  disease,  with  a  beginning,  middle,  and 
end,  like  typhoid  or  pneumonia.  It  comes  at  a  certain 
date  and  it  lasts  in  spite  of  anything  we  can  do  for  a 
certain  period;  then  it  stops,  not  because  of,  but  in 
spite  of,  anything  we  can  do  at  a  certain  time,  and 
the  person  is  perfectly  well.  These  attacks  tend  to 
recur.  I  have  known  people  who  had  only  one,  but  in 
most  cases  the  depression  and  excitement  come  again 

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A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

and  again  so  that  it  has  been  called  "circular  disease 
of  the  mind,"  even  sometimes  "circular  insanity." 
The  fundamental  fact  is,  it  recurs.  It  has  an  extraor- 
dinary tendency  to  come  in  the  autumn  and  early 
winter  months,  and  go  off  in  the  early  spring. 

The  two  phases  can  be  described  in  further  detail. 
The  depressed  phase  is  usually  the  first,  although  it  is 
the  second  irk  the  title,  and  it  often  comes  without  the 
other  phase  appearing  at  all.  This  phase  often  gets 
split  off  and  constitutes  the  whole  of  the  disease ;  that 
is,  a  long  period  of  intense  depression  is  the  whole 
thing.  It  differs  chiefly  in  degree  and  in  pertinacity 
from  the  ordinary  fit  of  the  blues.  Most  of  us  have  no 
occasion  to  analyze  a  fit  of  "  the  blues  "  and  see  how  ab- 
normal it  is.  In  "the  blues"  we  feel  that  there  never 
was  a  time  when  the  world  looked  any  better  than  it 
now  looks  and  there  certainly  never  will  be  such  a  time. 
That  is  a  characteristic  of  all  abnormal  mental  states, 
and  not  particularly  of  this  one ;  it  is  also  characteristic 
of  moods,  so  that  we  can  all  verify  its  characteristics 
in  our  own  experience.  In  winter  it  is  hard  to  remem- 
ber that  we  have  ever  been  too  warm,  and  in  summer 
we  cannot  believe  that  we  have  ever  been  or  ever  shall 
be  cool.  When  we  are  thoroughly  blue,  we  are  quite 
sure  that  we  were  never  of  any  use.  Moreover,  we  are 
quite  sure  that  our  friends  do  not  like  us. 

Intensify  all  that  and  we  have  the  depressed  phase 
of  this  trouble.  Self-reproach  is  intense  usually  in  this 
trouble ;  and  the  person  reproaches  himself  for  things 

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DISEASES  OF  THE  NERVOUS  SYSTEM 

he  never  did,  to  an  extent  that  would  be  ludicrous  if  it 
was  not  so  pitiful,  so  out  of  proportion  to  the  pecca- 
dilloes that  may  have  been  in  his  life.  I  sincerely  be- 
lieve that  we  are  all  of  us  "  miserable  sinners,"  but  the 
person  who  has  a  manic-depressive  psychosis  is  ab- 
normally conscious  of  this  fact  and  blames  himself,  not 
only  for  trifles,  but  for  sins  which  he  never  committed. 
Some  of  the  symptoms  that  make  us  know  that  this 
is  a  disease  and  has  nothing  to  do  with  character 
are  physical.  On  the  physical  side,  menstruation  in 
women  stops  often  only  to  reappear  at  the  end  of  the 
trouble.  Again,  all  muscular  motions  are  often  very 
slow;  people  get  stuck  in  a  fit  of  brooding  and  think 
they  cannot  move.  I  have  had  a  man  come  into  my 
office  and  sit  down  and  at  the  end  of  my  interview 
there  he  still  sat.  There  was  no  prospect  of  his  going 
anywhere.  An  hour  later  there  he  was  still  sitting.  He 
had  no  desire  and  no  initiative  to  move  elsewhere.  I 
have  seen  that  same  unfortunate  individual  stuck  on  a 
street  corner.  With  the  running  down  of  the  whole 
organism  the  initiative  for  motion  goes,  and  especially 
in  the  morning.  The  difficulty  in  getting  dressed  in  the 
morning  (which  some  of  us  may  have  at  some  time  ex- 
perienced) is  intensified  exceedingly.  Patients  feel  as 
if  they  could  never  get  going.  Their  spirits  and  their 
bodies  are  alike  at  their  worst  in  the  morning  and  their 
best  in  the  evening.  They  may  feel  somewhere  near 
decently  well  in  the  evening.  Their  very  worst  and 
blackest  moods  are  when  they  first  wake.  That  shows* 

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the  physical  side  of  the  thing  and  suggests  how  little 
it  has  to  do  with  character. 

This  depression  goes  on  for  a  variable  number  of 
weeks  or  months,  and  then  begins  to  turn  into  the 
other  type,  the  manic  phase,  or  perhaps  disappears 
without  any  manic  phase.  The  manic  phase  begins 
with  a  lack  of  concentration,  with  a  lack  of  responsi- 
bility, with  a  flightiness  which  is  cheerful.  The  person 
cannot  keep  at  anything;  he  jumps  from  subject  to 
subject  and  from  task  to  task.  [Of  course  we  have  his 
normal  self  to  contrast  this  with.  We  are  not  forgetting 
that  people  differ  enormously  in  their  capacities  for 
concentration.]  After  this  the  patient  may  go  on  to 
excitement  in  which  he  is  perpetually  and  on  the  whole 
excessively  happy.  It  does  not  seem  possible  that  a 
person  can  be  too  happy,  but  these  patients  are  happy 
in  a  way  that  makes  them  practically  incapable  of 
thinking  or  planning.  Their  happiness  drives  out  every 
other  activity  of  the  soul.  They  are  so  happy  that  they 
Jo  not  do  anything  steadily  nor  carry  out  their  plans. 

They  are  abnormally  affectionate.  A  great  many 
mistaken  engagements  of  marriage  take  place  in  this 
phase.  They  love  everybody,  which  is  good,  but  they 
do  not  moderate  their  transports  or  make  distinctions 
between  one  person  and  another.  They  are  often  a 
little  queer  about  money  matters  and  ^spend  extrava- 
gantly in  this  phase,  for  they  are  very  apt  to  be  in  error 
as  to  their  own  capabilities  and  resources,  not  only 
pecuniary  but  others.  They  recognize  how  extraor- 

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DISEASES  OF  THE  NERVOUS  SYSTEM 

dinarily  handsome,  strong,  successful  they  are,  and 
sometimes  their  fellows  do  not  recognize  it.  They  talk 
a  great  deal  and  are  always  in  the  front  row  of  every 
conversation.  They  may  seem  really  better  and 
brighter  than  their  normal  selves  in  many  respects, 
and  so  they  are,  perhaps,  but  they  cannot  keep  it  up. 
Moreover,  in  many  ways  they  are  foolish  or  deficient. 
It  is  very  hard  for  these  people  to  keep  still.  I  have 
said  that  the  other  type  of  person  comes  to  anchor,  as 
it  were,  and  stays  so.  But  in  the  manic  phase,  it  is  al- 
most impossible  to  make  the  patient  keep  still.  There 
is  perpetual  activity,  no  sense  of  fatigue ;  he  cannot  get 
tired,  does  not  need  to  sleep.  But  he  exhausts  himself 
at  this  time,  and  it  may  take  a  long  time  to  make  up 
for  the  drain  of  ceaseless,  untiring  activity. 

Throughout  the  whole  thing  the  person  is  rational. 
You  can  make  him  see  the  whole  trouble.  He  is  not 
insane.  He  can  be  brought  down  to  earth  and  will  take 
proper  care  of  himself  under  advice.  But  there  is  al- 
ways danger  that  the  trouble  will  become  so  intense 
that  it  merges  into  insanity  with  suicidal  impulse.  In 
the  severer  cases  confinement  or  perpetual  watching  is 
necessary  to  prevent  suicide. 

We  have  no  treatment  for  the  manic-depressive  psy- 
chosis. Nothing  we  do  makes  any  particular  difference. 
When  a  normal  person  is  a  little  blue,  if  you  take  him 
to  the  theatre  it  may  cheer  him  up,  but  in  this  psy- 
chosis an  attempt  to  entertain  may  make  him  more 
miserable  than  ever.  He  weeps  at  the  thing  that 

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amuses  us,  so  that  the  ordinary  efforts  to  cheer  him 
up  do  not  apply  here.  We  can  do  nothing  much  more 
than  wait  until  the  severe  phases  pass.  I  think  myself 
that  it  is  much  like  seasickness.  When  a  person  is 
thoroughly  seasick,  nothing  makes  the  slightest  differ- 
ence, but  as  soon  as  he  is  over  the  worst  of  it,  then  what 
he  does  and  what  we  do  make  a  great  difference.  So 
with  these  manic-depressive  sufferers;  the  time  that 
we  can  be  of  use  is  in  the  milder  early  stages  and  in  the 
late  convalescent  stages.  Then  by  the  same  efforts 
that  we  make  in  the  psychoneuroses,  by  the  attempt 
to  draw  the  patient  into  normal  relations  with  the  life 
and  people  around  him,  we  may  help  him.  Medicines 
have  no  effect,  of  course,  in  this  disease.  The  worst 
thing  that  anybody  can  do  is  to  give  a  sleeping-potion, 
which  adds  a  drug  habit  to  the  troubles  already  in 
existence. 

Questions  and  Answers 

Q.  Is  this  disease  something  that  is  easily  recognized  as 
abnormal,  or  might  it  go  on  and  not  be  recognized? 

A.  It  may  easily  go  on  and  not  be  recognized. 

Q.  Do  you  think  it  is  chemical  in  origin? 

A.  I  think  the  evidence  will  probably  show  some  day 
that  it  is  chemical;  that  is,  that  there  is  something  wrong  in 
the  chemistry  of  our  bodies  whereby  poisonous  substances 
accumulate,  poison  both  body  and  brain,  and  then  are  fi- 
nally worked  off.  There  is  no  proof  of  that,  however,  as  yet. 
A  great  deal  of  chemical  research  has  been  devoted  to  an 
attempt  to  prove  it,  but  it  remains  a  plausible  hypothesis. 

Q.  What  is  the  best  method  of  persuading  them  what 
their  duty  should  be? 

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DISEASES  OF  THE  NERVOUS  SYSTEM 

A.  I  know  no  definite  way. 

Q.  What  if  they  show  violence? 

A.  If  it  is  really  violence,  then  we  have  crossed  the  bor- 
der into  insanity.  Most  patients  are  perfectly  reasonable, 
but  at  any  time  this  disease  may  cross  the  border  into  a 
region  where  you  cannot  reason.  You  can  imagine  a  person 
being  so  exuberant  during  the  manic  periods  that  he  has  to 
be  restrained.  Then  it  is  insanity.  At  the  other  extreme, 
which  is  commoner,  people  get  so  depressed  that  they  are 
suicidal.  The  distinction  between  sane  and  insane  is  always 
a  purely  practical  one  —  What  does  the  person  do  and  how 
far  is  he  amenable  to  reason?  When  a  person  gets  beyond 
any  rational  control,  even  though  his  symptoms  are  the  same 
as  before,  then  he  is  insane. 

Q.  Do  emotions  bring  about  this  disease? 

A.  All  of  our  emotions  change  the  chemistry  of  the  body. 
It  has  been  proved  by  Dr.  Cannon,1  that  fear,  anger,  ex- 
citement, and  probably  every  emotion  has  a  perfectly  defi- 
nite effect  upon  the  body,  pushes  sugar  out  of  the  liver  and 
into  the  blood,  stimulates  the  suprarenal  glands,  affects  the 
coagulation,  of  the  blood,  etc.  In  the  manic-depressive  psy- 
chosis I  think  it  is  the  other  way.  Chemical  changes  beget 
emotions.  Body  and  mind  act  each  upon  the  other  and  each 
may  be  the  initiator;  so  that  the  mind  can  bring  about 
diseases  of  the  body  as  Dr.  Cannon  showed.  But  the  body 
can  also  bring  about  diseases  of  the  mind,  as  in  syphilitic 
insanity. 

Q.  Has  anybody  studied  this  psychosis  as  dementia 
precox  has  been  studied? 

A.  I  should  say  yes.  There  has  been  a  great  deal  of  work 
done  at  the  McLean  Asylum  in  that  line,  but  so  far  without 
any  success.  I  do  not  as  yet  feel  convinced  that  we  are  really 
doing  anything  for  the  cure  of  dementia  precox.  I  think  we 
shall  have  to  wait  a  good  while  for  it. 

1  Dr.  Walter  B.  Cannon,  Bodily  Changes  in  Pain,  Hunger,  Fear,  and 
Rage.  New  York,  1915. 

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Another  much  less  common  psychosis  goes  under  the 
term  of  the  exhaustion  psychosis,  and  is  seen  especially 
at  the  end  of  infectious  diseases.  Once  in  so  often,  in 
every  hundred  cases  of  typhoid  or  pneumonia  or  even 
tonsillitis  (as  I  have  seen),  there  comes  a  psychosis 
which  must  be  due  in  some  way  to  the  effects  of  the 
poisons  of  the  disease.  (This  tends  to  make  us  think 
that  the  other  psychoses  are  also  due  to  poisons.)  The 
exhaustion  psychosis  is  shown  particularly  by  a  be- 
wildered state;  the  patient  is  not  much  depressed,  not 
much  excited,  but  very  much  bewildered  or  disori- 
ented, which  means,  literally ,^that  he  does  not  know 
the  points  of  the  compass.  The  patient  does  not  know 
where  he  is ;  he  has  delusions  or  false  beliefs,  and  hal- 
lucinations (false  sight  and  hearing,  false  smell  and 
taste).  If  I  believe  that  you  are  the  devil  incarnate, 
that  is  a  delusion;  but  if  I  believe  that  I  now  hear 
a  bell  ringing  loudly,  that  is  a  hallucination.  Hallu- 
cinations are  strictly  sensations,  hearing,  sight,  taste, 
smell.  Hallucinations  of  taste  and  smell  are  very 
common;  people  very  often  think  their  food  is  poi- 
soned and  fancy  they  can  taste  the  poison. 

The  most  important  fact  about  this  exhaustion  psy- 
chosis is  that  the  patients  almost  always  get  well  and 
stay  well.  One  feeds  the  patient,  keeps  him  as  quiet 
as  possible,  and  in  a  little  while  the  trouble  passes 
off,  in  a  few  weeks  possibly.  It  has  no  tendency  to 
recur. 


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DISEASES  OF  THE   NERVOUS  SYSTEM 

In  all  I  have  said  so  far  I  have  been  pretty  negative 
so  far  as  treatment  is  concerned.  I  do  not  think  there 
is  any  treatment  for  the  psychoses.  I  do  not  say  that 
there  never  will  be,  but  so  far  there  is  none.  One  does 
what  one  can  to  mitigate  the  symptoms,  to  palliate 
suffering,  but  one  does  not  treat  the  disease.  There  is 
no  mental  treatment.  We  try  to  get  the  bowels  regu- 
lar, to  keep  the  skin  in  good  condition,  to  promote 
sleep,  but  we  have  given  up  trying  to  affect  the  mind 
itself,  because  we  cannot.  The  mind  comes  round  to 
health,  if  it  can  come  round,  as  a  result  of  treating  the 
body. 

The  only  other  psychosis  that  should  be  mentioned 
is  the  psychosis  of  the  puerperal  state,  coming  before  or 
after  the  birth  of  a  child,  probably  very  close  to  the  ex- 
haustion psychoses,  certainly  due  to  self-poisoning  of 
some  kind.  It  is  usually  of  the  same  type  as  the  exhaus- 
tion psychoses,  but  there  may  be  depression  with  it, 
rarely  excitement.  Its  prognosis  is  usually  good,  but  it 
may  recur  with  the  next  child.  It  is  facts  like  these,  facts 
like  the  relation  of  psychosis  to  pregnancy  and  to  acute 
fevers,  that  make  us  believe  that  there  are  no  diseases 
of  the  mind.  There  are,  we  believe,  diseases  of  the  whole 
person,  body  and  mind,  but  no  diseases  of  the  mind. 
The  alcoholic  is  diseased  in  his  body  and  his  mind ;  the 
typhoid  patient  is  diseased  in  his  body  and  his  mind 
(delirium) ;  but  they  have  not  a  separate  disease  of  the 
mind  itself. 


CHAPTER  X 

DISEASES  OF  THE  NERVOUS  SYSTEM  (CONTINUED) 

I.  Moods 

f  Neurasthenic 

Hysteric 

II.  Psychoneuroses  •<  Psychasthenic 

I  Traumatic 
L  Visceral 
(  Manic-depressive 

III.  Psychoses  -j  Exhaustive 

(  Parturient 

f  Precocious  dementia 

I  Syphilitic  dementia 

IV.  Insanities  <  Senile  and  arteriosclerotic  dementia 

Paranoia 

t  Alcoholic  insanity 
V.  Mental  Deficiencies 

INSANITY  cannot  be  defined.  I  was  glad  to  hear  that 
restated  recently  at  the  State  House  by  Dr.  Elmer  E. 
Southard,  who  has  a  right  to  speak  on  this  subject. 
Patients  are  treated  and  legally  committed  upon  the 
basis  of  practical  considerations,  and  not  of  scientific 
definitions.  One  says,  "This  person  is  dangerous  to 
have  in  the  community."  We  may  be  all  insane,  but 
most  of  us  are  harmless;  we  do  not  make  much  trouble 
in  the  community,  so  that  it  is  not  worth  while  to  com- 
mit us.  But  when  we  pass  that  point  and  begin  to 
make  trouble,  we  begin  to  be  called  insane. 

The  insanities  are  diseases  of  the  body  and  mind  to- 
gether, not  of  the  mind  separately,  so  far  as  any  one 

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DISEASES  OF  THE   NERVOUS  SYSTEM 

knows  at  the  present  time.  I  dwelt  in  the  last  chapter 
upon  two  great  contrasted  emotional  states,  excite- 
ment and  depression.  There  is  a  third  great  emotional 
state  which  is  contrasted  with  them  both,  as  indiffer- 
ence, profound  lethargy  or  inactivity,  emotional  neu- 
trality. That  is  the  main  characteristic  of  the  state 
known  as  dementia.  Whereas  in  excitement  one  has 
a  very  high,  keyed-up  state,  and  in  depression  a  very 
sad,  depressed  state,  in  the  demented  states  people  are 
simply  profoundly  indifferent.  They  sit  like  a  bump  on 
a  log,  and  look  like  the  farmer  who  said  when  there 
was  nothing  to  do  in  winter,  he  would  "just  sit  and 
think,  and  sometimes  just  sit."  Literally  they  may 
sit  for  months  and  years  and  vegetate,  free  from  any 
emotion  of  happiness  or  unhappiness,  purely  animal 
or  vegetable  creatures.  A  great  many  other  insanities 
tend  to  dementia  as  their  end-state.  They  are  split  off 
into  various  active  and  dangerous  forms,  but  end  in 
the  purely  passive,  inert,  unemotional  indifference, 
mindless  dementia.  ' '  Dementia ' '  means  literally  mind- 
lessness,  the  absence  of  any  mental  activity  at  all. 

There  are  three  great  groups,  dementia  precox, 
syphilitic  dementia  (which  has  various  other  names,  to 
be  given  later),  and  the  sejiile,  or  arteriosclerotic  form. 

Precocious  dementia,  or  dementia  precox,  is  one  of  the 

• 

best  studied  types  of  insanity.  It  forms  a  steady  and 
considerable  percentage  of  all  the  insanities  in  asylums 
and  presents  a  great  many  mysteries.  In  contrast  with 
the  excited  and  depressed  states,  the  patient  with 

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dementia  precox  is  usually  neither  excited  nor  de- 
pressed, but  fundamentally  silly.  He  can  easily  be 
forced  to  reason  if  you  can  break  through  his  habit- 
ual silliness.  The  disease  comes  on  usually  in  the  early 
adult  life,  at  college  time,  at  the  time  from  eighteen  to 
twenty-two  or  a  little  later,  and  it  seems  as  if  a  per- 
son's mind,  after  developing  up  to  a  certain  point, 
stopped  and  retrograded  as  we  are  accustomed  to  see 
it  in  old  age.  That  is  why  it  is  spoken  of  as  "preco- 
cious," the  process  which  is  natural  in  old  age  coming 
on  in  a  very  unnatural  way  in  youth.  One  does  not 
make  this  diagnosis  in  elderly  people  because  then  it  is 
not  precocious. 

I  have  spoken  of  silliness  as  one  of  the  characteristic 
marks;  another  is  repetition,  a  stereotyped  way  of 
saying  the  same  things  over  and  over;  certain  motions, 
gaits,  attitudes,  which  become  habitual.  If  one  walks 
through  an  asylum  one  often  sees  people  sitting  or 
standing  in /very  queer  attitudes. 

A  third  characteristic  is  resistance  to  whatever  is 
said  or  desired.  They  often  won't  eat,  walk,  go  to  bed, 
take  their  clothes  off,  keep  their  clothes  on.  The  dis- 
ease sometimes  gets  to  a  point  where  in  order  to  get 
the  patient  to  do  a  thing,  we  tell  him  the  opposite; 
sometimes  that  is  actually  effective.  This  resistance 
may  go  so  far  that  it  becomes  intense  and  muscular. 
Patients  become  rigid,  like  a  log,  and  resist  attempts 
to  move  them  or  bend  their  muscles.  That  particular 
form  is  called  the  "catatonic"  form.  The  tendency 

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DISEASES  OF  THE   NERVOUS  SYSTEM 

to  do  the  opposite  of  what  we  ask  is  sometimes  called 
"  negativism."  So  that  we  often  hear  cases  described 
as  stereotyped,  negative,  catatonic. 

The  disease  is  a  very  mysterious  one,  and  the  most 
mysterious  thing  about  it  is  that  it  occasionally  gets 
well.  The  vast  majority  go  on  from  bad  to  worse  and 
have  to  remain  under  asylum  care  all  their  lives.  On 
the  other  hand,  just  often  enough  to  make  us  unable  to 
dogmatize,  a  case  entirely  recovers  after  years  of  mind- 
less vegetation.  Where  the  mind  has  been  all  this  time, 
or  what  has  been  happening,  we  have  no  means  of 
conceiving.  We  should  suppose  that  the  brain  must 
be  permanently  diseased  and  the  possibility  of  mental 
action  gone. 

For  the  syphilitic  dementia,  the  next  type,  we  have, 
as  I  have  said,  many  terms:  it  is  known  as  paresis,  as 
dementia  paralytica,  or  general  paralysis  of  the  insane, 
or  as  "softening  of  the  brain"  —  which  is  exactly  the 
opposite  of  the  truth,  for  the  brain  really  hardens. 
This  is  the  type  of  insanity  in  which  we  have  the  best 
known  pathology.  The  brain  in  many  insanities  shows 
nothing  whatever  after  death,  but  in  syphilitic  demen- 
tia there  are  characteristic  degenerations  in  the  brain. 

Syphilitic  dementia  is  enormously  common  as  an 
end-result  of  syphilis,  and  makes  somewhere  about 
forty  per  cent  of  the  total  population  of  any  system  of 
insane  asylums.  It  is,  in  its  later  stages,  absolutely  in- 
curable. In  early  stages  it  is  helped  to  some  extent  by 
the  modern  salvarsan  therapy  which  has  helped  most 

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of  the  other  forms  and  results  of  syphilis.  It  is  the  most 
important,  probably,  of  all  insanities  for  social  workers 
to  know,  because  it  is  so  common  and  in  early  stages  so 
easily  escapes  detection,  although  in  late  stages  it  is 
usually  easy  of  diagnosis.  The  early  stages  show  them- 
selves, in  most  cases,  first,  by  a  change  in  behavior  or 
temperament :  a  person  who  has  always  been  polite  and 
punctual  begins  to  be  bad-mannered  and  dilatory;  a 
person  always  precise  and  neat  in  his  dress  begins  to 
make  bad  mistakes  in  that  direction ;  a  person  always 
considerate  in  family  relations  begins  to  be  fearfully 
inconsiderate.  These  comparatively  slight  changes  in 
temperament  are  among  the  earliest  that  we  see.  At 
this  time  the  patient  is  very  apt  to  be  mistaken  for  one 
of  the  psychoneurotics.  He  is  often  nervous,  shaky  or 
fidgety,  and  comes  to  the  doctor  saying,  "I  am  nerv- 
ous; I  want  something  for  my  nerves." 

Besides  the  nervous  restlessness  and  the  tempera- 
mental changes  one  of  the  earliest  symptoms  may  be 
failure  or  lapse  in  the  arithmetical  faculty.  A  person 
who  can  ordinarily  add  simple  sums  loses  his  previous 
power.  I  remember  a  paretic  physician  who  was  still 
able  to  carry  on  his  practice  in  other  respects,  but 
could  not  write  his  prescriptions  or  add  his  accounts. 
In  people  who  never  had  any  such  tendency  before 
there  comes  a  tendency  to  trembling  in  the  hands  and 
lips.  All  these  things  are  important  when  seen  against 
a  background  of  known  health ;  they  would  not  be  im- 
portant if  they  were  habitual  or  life-long  habits.  It  is 

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DISEASES  OF  THE   NERVOUS  SYSTEM 

when  they  suddenly  appear  in  a  person  of  forty  or  so 
that  they  have  a  special  significance. 

Sooner  or  later  there  come  attacks  of  unconscious- 
ness, falling,  or  losing  consciousness  in  the  street  or.  at 
table,  with  or  without  convulsions.  Then  come  more 
classic  and  easily  recognized  stages,  characterized  by 
what  are  called  ''delusions  of  grandeur,"  not  so  very 
different  from  what  we  see  in  the  excited  stage  of  a 
psychosis.  Patients  discover  suddenly  that  they  are 
enormously  rich  and  very  handsome  and  clever. 

All  this  so  far  sounds  quite  harmless,  but  it  is  espe- 
cially important  to  know  that  out  of  such  a  compara- 
tively harmless  state  of  things  the  most  violent  homi- 
cidal impulses  suddenly  emerge.  There  is  no  type  of 
insanity  so  dangerous  as  this,  just  because  it  seems 
most  of  the  time  so  harmless.  Hence  none  of  the  types 
previously  described  is  such  a  menace  to  the  general 
public. 

The  diagnosis  is  made  much  easier  of  late  years  by 
the  various  biological  tests  for  syphilis.  It  was  not 
realized  until  the  last  few  years  that  this  disease  is 
always  caused  by  syphilis,  and  hence  that  tests,  not 
only  of  the  blood,  but  of  the  fluid  that  circulates 
through  the  spinal  column,  are  valuable  in  diagnosis. 
We  do  not  have  to  rest  our  diagnosis  wholly  upon  the 
mental  tests ;  we  are  able  to  get  some  physical  evidence 
as  well,  in  the  Wassermann  and  spinal  fluid  tests,  as 
well  as  in  the  pupils,  the  reflexes,  etc. 

In  about  four  per  cent  of  cases,  there  come  periods 

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of  spontaneous  arrest  when  for  the  time  being  it  does 
not  get  any  worse.  But  unless  treated  early  it  goes  on 
to  the  mindless  and  paralyzed  condition  whereby  it 
gets  its  name.  This  may  last  for  years,  usually  in  an 
asylum. 

The  senile,  or  arterio  sclerotic  dementia,  is  an  exagger- 
ation of  the  peculiarities  of  old  age.  We  all  know  the 
comparatively  " normal"  peculiarities  of  old  age  — 
the  lack  of  initiative,  the  unwillingness  to  undertake 
anything  new,  the  coldness  toward  enthusiasm,  the 
tendency  to  retire  into  a  corner  and  stay  there,  the 
unreadiness  to  be  drawn  out  from  the  fireside  into  any 
activity,  the  lapses  of  memory,  the  garrulous  repeti- 
tions, the  increased  timidity,  the  slight  tendency  to 
suspicion  and  to  hurt  feelings.  All  of  this  we  recog- 
nize as  within  the  lines  of  the  normal;  it  becomes 
accentuated  in  the  senile  dementias.  vThe  individual 
becomes  unable  to  accomplish  anything,  to  concen- 
trate attention  on  anything,  becomes  very  distrustful 
of  himself,  becomes  silly,  tells  his  stories  not  only  once 
or  twice,  but  innumerable  times,  forgets  that  he  has 
said  a  thing  a  few  minutes  before.  As  a  rule  the  trouble 
is  perfectly  harmless;  in  fact  I  cannot  remember  an 
exception.  Hence  the  patient  almost  never  needs  to 
be  committed  to  an  asylum.  Almost  always,  if  there 
are  any  relations,  he  can  remain  at  home.  The  disease 
is  a  very  gradual  process,  not  entailing  very  much  un- 
happiness  as  insanities  go.  Because  it  often  goes  along 
with  arteriosclerosis,  as  I  have  indicated,  it  may  show 

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DISEASES  OF  THE  NERVOUS  SYSTEM 

the  headaches,  dizziness,  and  failing  heart  which 
arteriosclerosis  entails.  There  is  no  treatment. 

Paranoia  is  a  very  unsatisfactory  term.  I  do  not 
think  any  of  the  alienists  are  satisfied  with  it.  It  is 
not  a  clear-cut  conception  like  the  others  I  have  been 
speaking  of.  But  at  present  there  is  no  better  term  for 
a  series  of  cases  in  which  a  person  is  wholly  irrational 
on  one  set  of  subjects,  and  perfectly  sane  on  anything 
else.  We  may  talk  with  the  paranoiac  for  hours  on  all 
sorts  of  subjects,  and  then,  if  we  have  luck,  of  a  sudden 
the  conversation  will  take  a  turn  and  he  will  begin  to 
tell  you  that  the  President  of  the  United  States  and  the 
Emperor  of  Russia  have  been  conspiring,  and  have 
succeeded  in  having  all  linen  collars  made  at  such  a 
height  that  it  is  impossible  for  him  to  put  his  head 
back  comfortably.  Why  it  is  they  do  this  particular 
thing  it  is  impossible  for  him  to  say.  He  is  perfectly 
cheerful.  He  is  not  either  depressed  or  excited  or  de- 
mented, but  he  is  entirely  "  off  "  on  some  one  subject 
or  group  of  subjects,  and  as  a  rule  his  irrationality  takes 
the  form  of  a  delusion  of  persecution.  When  a  person 
has  only  one  delusion  isolated  from  all  the  rest  of  his 
(relatively  normal)  life,  that  is  generally  a  delusion 
that  the  world  is  in  a  conspiracy  against  him.  Every- 
body has  a  grudge  against  him  and  is  trying  to  make 
his  life  unhappy. 

The  person's  clearness  and  sincerity  are  very  apt 
to  mislead  us.  Surely,  we  say,  this  person  has  been 
wronged,  falsely  thrown  into  confinement.  Until  we 

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have  been  through  one  or  two  of  those  cases  we  can 
hardly  believe  that  we  are  not  in  the  way  of  rescuing 
some  unfortunate  person  from  the  clutches  of  the  un- 
just. But  in  trying  to  look  up  some  of  their  statements 
to  find  if  they  are  true,  we  find  out  the  actual  state  of 
things.  Often  they  become  dangerous.  Some  years  ago 
a  Harvard  professor's  cook,  a  quiet,  harmless  body, 
suddenly  decided  that  if  the  Dean  and  the  other  pro- 
fessors of  Harvard  University  did  not  stop  interfering 
with  her  affairs  she  would  have  to  burn  down  the  pro- 
fessor's house,  and  she  rather  thought  that  she  would 
have  to  do  it  that  night. 

I  remember  another  lady  who  discovered  that  all  the 
boarding-house  keepers  were  leagued  in  a  conspiracy 
against  her,  and  I  had  to  go  to  some  of  these  before  I 
got  a  straight  story.  I  found  that  the  old  lady  was  so 
exceedingly  disagreeable  that  she  could  not  be  kept 
in  any  boarding-house,  and  they  had  passed  the  word 
along.  Beware  of  anybody  who  conies  to  you  with  a  story 
of  conspiracy,  of  the  working  together  of  various  people 
to  shoot  down  destruction  on  one  innocent  head. 

" Paranoia"  is  a  word  that  has  been  invoked  a  good 
deal  by  unprincipled  lawyers  and  others  to  get  sane 
people,  who  have  committed  murder,  off  from  their  just 
deserts.  One  tries  to  prove  that  the  person  tempora- 
rily is  beside  himself  and  commits  murder  under  stress 
of  insanity.  And  because  we  know  so  little  about  the 
disease,  because  its  symptoms  are  so  vague,  its  name 
can  be  employed  in  this  way  for  purposes  of  fraud. 

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DISEASES  OF  THE   NERVOUS  SYSTEM 

Another  name  of  this  disease  is  systematic  delusional 
insanity,  because  the  person  has  a  regular  system  of 
delusions,  not  varying  from  day  to  day,  not  covering 
all  topics,  but  centring  round  some  one,  contrasting 
sharply  with  depressed  and  excited  states,  and  with 
demented  states.  The  disease  is  comparatively  rare, 
and  as  a  public  charge  therefore  comparatively  small. 
It  is  chronic  and  generally  incurable,  but  sometimes 
shows  partial  or  complete  remissions.  I  have  a  patient 
now  who  seems  to  have  been  very  much  helped  by 
Christian  Science,  and  as  long  as  she  lives  with  a 
Christian  Scientist  she  seems  to  get  on  pretty  well. 
Many  of  these  patients  need  not  be  put  in  asylums, 
but  can  stay  at  home. 

Alcoholic  insanity  makes  up  a  large  group  of  the 
cases  in  any  system  of  public  hospitals.  It  is  not  nearly 
as  well  defined  as  to  mental  symptoms  as  the  other 
types  of  insanity,  but  there  are  two  marks  by  which 
we  can  distinguish  a  good  many  cases:  (i)  An  extraor- 
dinary failure  of  memory.  Memory  fails  more  or  less 
in  all  insanities,  but  extraordinarily,  out  of  proportion 
to  any  other  mental  change,  and  as  an  isolated  phe- 
nomenon in  some  of  the  alcoholic  insanities.  I  have 
seen  a  man  whose  memory  was  so  completely  gone 
that,  while  he  could  hold  an  ordinary  conversation 
with  me,  if  I  went  out  of  the  room  and  stayed  out  three 
minutes  and  returned,  he  would  have  absolutely  for- 
gotten that  he  had  seen  me  before.  (2)  The  other 
characteristic  is  the  tendency  to  hallucinations,  that 

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is,  to  mistaken  sense  perceptions.  That  shows  itself 
in  all  types  of  alcoholic  insanity,  even  in  the  famil- 
iar delirium  tr  emeus,  in  which  men  are  apt  to  "see 
snakes,"  also  cats,  beetles,  and  all  sorts  of  things,  that 
are  not  there.  A  curious  fact  is  that  whatever  they  see 
is  usually  black.  They  have  other  delusions  of  sense, 
delusions  of  hearing,  and  they  may  have  systematic 
delusions  like  those  of  a  paranoiac,  but  they  always 
have  other  mental  changes,  not  the  isolated  system  of 
delusions  that  the  paranoiac  has.  Some  get  wholly 
well,  some  partially  well,  some  lapse  into  demented 
states  and  live  out  their  lives  in  asylums. 

If  we  can  abolish  alcohol  and  syphilis,  we  can  abolish 
more  than  half  of  insanity.  Inheritance  accounts  for 
almost  all  the  rest.  Hence  it  is  conceivable,  ideally 
possible  almost  to  abolish  insanity.  Personally  I  do 
not  think  we  shall  ever  have  much  power  over  it 
therapeutically. 

Questions  and,  Answers 

Q.  Can  a  case  of  paranoia  have  complete  recovery? 

A.  Yes;  so  far  as  I  know,  yes. 

Q.  Do  drugs  sometimes  cause  insanity? 

A.  Yes ;  alcohol  is  a  drug  that  causes  insanity,  and  cocaine 
or  chloral  sometimes  cause  insanity  or  mental  deterioration. 

Q.  Does  the  insanity  that  comes  from  overstudy  come 
under  dementia? 

A.  There  is  no  such  insanity.  Insanity  is  never  due  to  any 
of  the  causes  mentioned  in  novels  —  never  due  to  love,  over- 
work, or  any  mental  cause  whatsoever.  We  hear  about 
those  things  constantly,  but  never  find  it  true  if  we  follow 

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DISEASES  OF  THE  NERVOUS  SYSTEM 

the  story  up.  The  person  is  insane;  he  then  overworks;  we 
discover  the  overwork,  but  we  do  not  discover  the  insanity. 
He  was  really  insane  before  he  overworked,  or  before  he  was 
disappointed  in  love.  Men  are  said  to  come  out  of  the 
trenches  in  France  insane,  but  the  doctors  say  that  they  are 
not  really  insane,  but  fearfully  strained,  or  hysterical;  they 
may  even  have  a  temporary  psychosis,  but  they  are  not 
insane,  they  get  well.  Certainly,  then,  take  it  to  heart,  that 
mental  causes  and  overwork  do  not  cause  insanity. 

Q.  Would  it  be  considered  a  favorable  symptom  in  de- 
mentia paralytica  if  the  patient  had  lucid  intervals? 

A.  Yes,  favorable,  but  not  proving  that  he  was  going  to 
get  well.  These  lucid  intervals  are  common.  Sometimes  a 
person  with  a  powerful  personality  can  shake  the  patient  out 
of  his  dementia  for  a  time,  but  he  relapses  again  a  little  later. 

The  mental  deficiencies  belong  in  a  wholly  different 
group.  They  are  distinguished  from  insanity,  in  the 
first  place,  because  they  have  a  perfectly  definite  phy- 
sical basis,  in  lack  of  development  of  the  brain ;  in  the 
second  place,  as  being  a  lack  rather  than  a  perversion, 
a  congenital  and  incurable  weakness.  It  is  a  weakness 
of  mind,  but  not  a  disease  of  mind,  and  always  a  con- 
genital, not  an  acquired  thing. 

We  distinguish  three  grades :  the  lowest  is  the  idiot, 
a  person  unable  to  care  for  his  own  person,  unable  to 
control  his  water,  unable  to  feed  himself,  below  the 
animals.  Next  comes  the  feeble-minded,  who  can  care 
for  his  own  wants,  but  is  quite  unable  to  get  along 
outside  an  asylum  or  without  very  close  protection. 
Lastly,  the  moron  group  (moron  being  the  Greek  word 
for  fool) ;  the  village  fool  of  old  times,  who  is  often, 

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except  by  an  expert,  indistinguishable  from  normal 
persons,  has  an  excellent  appearance,  can  talk  intelli- 
gently on  many  subjects,  but  is  forever  unable  to  go 
without  a  hand  on  the  shoulder,  without  some  guid- 
ance. 

The  first  two  types  are  comparatively  harmless  sex- 
ually, and  the  last  type  is  the  most  dangerous  of  all. 
All  are  uncontrolled  sexually,  but  the  last  type  is 
specially  dangerous  in  the  community. 

The  history  of  these  cases  is  often  more  important 
than  the  direct  mental  examination.  When  did  the 
child  walk?  When  did  the  child  talk?  When  first  have 
its  teeth?  These  are  the  three  questions  on  which 
every  expert  dwells  with  special  care.  Children  who 
do  not  walk  until  two  or  three  and  do  not  talk  until 
three  or  four  are  under  great  suspicion,  even  if  we  are 
without  any  further  knowledge  about  them.  I  shall 
not  attempt,  of  course,  to  go  into  any  of  the  mental 
tests  or  the  finer  points.  There  are  several  systems,  the 
simplest  and  most  generally  used  being  the  Binet, 
which  on  the  whole  is  extraordinarily  useful  in  chil- 
dren of  the  school  age,  but  is  not  applicable  to  older 
people  unless  their  mentality  is  that  of  school-chil- 
dren. Dr.  Healy  l  has  tests  for  the  adolescent  years 
beyond  school  age,  and  there  are  others,  no  doubt  good 
in  the  hands  of  the  people  that  invented  them. 

It  is  essential  to  distinguish  feeble-mindedness  or 
mental  deficiency  from  the  mental  retardation  due  to 

1  William  Healy,  The  Individual  Delinquent.   Boston,  1915. 
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DISEASES  OF  THE   NERVOUS  SYSTEM 

deafness  or  blindness,  which,  if  they  come  on  early  in 
the  child's  life,  may  prevent  the  development  of  the 
child's  mind  almost  as  much  as  feeble-mindedness 
does,  but  which  yet  may  yield  somewhat  to  proper 
treatment.  I  suppose  Helen  Keller  would  have  been 
an  idiot  or  a  feeble-minded  girl  if  she  had  not  had  ex- 
traordinary advantages  in  education.  When  she  was 
first  in  the  blind  asylum  there  was  a  deaf  and  blind  boy 
about  the  same  age,  Tommy  Stringer,  whom  many  then 
followed  with  equal  interest.  It  looked  as  if  both  were 
to  be  drawn  out  of  the  prison  house,  but  Tommy  never 
had  so  remarkable  a  teacher  and  he  never  has  devel- 
oped into  a  normal  boy  mentally.  He  still  is  distinctly 
deficient.  It  is  important  that  an  expert  examination 
should  distinguish  these  cases  for  which  there  is  hope, 
in  which  the  brain  is  not  deficient  but  only  the  senses, 
from  the  true  mental  defects  in  which  there  is  no  hope. 

The  parents  of  feeble-minded  children  are  wonder- 
fully slow  to  see  or  to  admit  the  defect.  Some  acciden- 
tal peculiarity,  some  lack  of  education,  some  failure 
of  general  health  is  usually  all  that  the  parent  sees. 
Sometimes  there  is  a  story  that  some  one  "  dropped 
the  baby,"  or  some  other  accident  is  supposed  (quite 
falsely)  to  account  for  the  trouble. 

This  blindness  in  parents  often  makes  it  difficult  to 
secure  from  them  the  permission  to  commit  the  child 
to  an  institution  where  in  most  cases  he  should  remain 
for  life,  because  he  hinders  other  children  intellectually 
and  corrupts  them  morally  in  school  or  out  of  it. 

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Judges  as  well  as  parents  have  still  much  to  learn 
about  the  dangers  of  leaving  the  feeble-minded  at  large 
in  the  community,  and  about  the  relation  of  feeble- 
mindedness to  crime. 

Since  the  trouble  is  usually  hereditary,  and  since  the 
feeble-minded  beget  feeble-minded  children,  state  pro- 
vision of  institutional  care  is  essential  in  order  to  pre- 
vent grave  racial  degeneration. 

Out  of  feeble-mindedness  comes  by  heredity  a  vast 
amount  of  alcoholism,  prostitution,  insanity,  pauper- 
ism, and  crime.  Whatever  is  done  to  prevent  by  custo- 
dial care  the  procreation  of  the  feeble-minded  strikes 
at  the  root,  not  only  of  this  evil,  but  of  all  the  worse 
evils  against  which  social  workers  are  striving  both  in 
cities  and  in  country  districts.  No  other  social  problem 
is  so  important,  because  none  is  at  once  so  widely 
menacing  and  so  curable. 

Q.  When  do  teeth  come  in  feeble-minded  children? 
A.  They  come  too  late.  Many  do  not  get  any  teeth  until 
the  second  year. 

Diseases  of  the  Brain ,  Spinal  Cord,  and  Nerves 

The  commonest  disease  of  the  brain  is  known  as  apo- 
plexy. Apoplexy  is  the  familiar  " shock"  of  old  people, 
and  is  due  to  defect  in  the  brain  arteries  —  not  always 
to  the  same  defect ;  sometimes  due  to  the  plugging  of  a 
vessel,  sometimes  to  the  narrowing  of  a  vessel,  some- 
times to  the  breaking  of  a  vessel  —  but  in  all  cases  to 
something  wrong  with  an  artery  of  the  brain.  If  it 

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DISEASES  OF  THE  NERVOUS  SYSTEM 

comes  in  people  below  forty-five,  syphilis  should  al- 
ways be  suspected.  Ordinarily  we  see  it  in  people  of 
fifty- five  to  seventy ;  it  produces  a  sudden  coma  or  un- 
consciousness, more  or  less  complete,  perhaps  only  a 
sleepy  state,  accompanied  almost  always  by  either  pa- 
ralysis or  aphasia,  or  both.  There  is  usually  no  paraly- 
sis of  the  tongue ;  it  is  only  that  the  connection  be- 
tween the  brain  and  the  speaking  function  is  lost. 

One  of  the  very  interesting  types  of  apoplexy  is 
where  we  have  what  we  call  "word  deafness*' :  the  per- 
son hears  what  you  say,  he  is  not  deaf,  but  words  con- 
vey no  meaning;  the  sounds  fall  on  the  ear,  but  have 
no  sense.  The  patient  may  be  able  to  talk,  but  his  own 
words  also  convey  no  meaning.  He  does  not  know 
what  he  is  saying.  This  is  sensory  aphasia  as  dis- 
tinguished from  motor  aphasia.  Sometimes  the  patient 
can  read  but  not  speak,  understands  the  written  char- 
acter but  not  the  spoken  character.  Most  of  these 
cases  get  well. 

Q.  Are  the  words  that  they  read  or  speak  connected  or 
are  they  disjointed? 

A.  Sometimes  there  are  perfectly  connected  sensible  sen- 
tences, sometimes  these  patients  can  speak  a  few  words,  but 
no  more  —  quite  often  two  words.  Then  they  use  these  two 
words  for  everything,  and  are  not  aware  that  they  have  not 
made  sentences. 

The  common  paralysis  is  hemiplegia,  or  half  the 
body,  the  arm  and  leg  on  the  same  side.  The  attack 
may  be  immediately  fatal,  but  the  first  attack  is  usu- 

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ally  not.  If  it  is  not  fatal  the  person  is  left  with  more 
or  less  paralysis,  more  or  less  difficulty  of  speech,  and 
more  or  less  mental  impairment.  I  have  never  seen  a 
person  in  whom  there  was  not  some,  although  some- 
times slight,  mental  impairment.  This  is  the  type 
which  we  distinguish  from  the  hemiplegias  which  come 
under  heart  disease,  from  the  breaking  off  of  a  bit  of 
clot  formed  in  the  heart.  That  type  (the  cardiac  type) 
gets  well.  The  cerebral  type  gets  better,  but  never,  I 
think,  gets  wholly  well. 

One  sees  a  great  many  of  these  poor  old  hemiplegics 
about  the  nerve  clinics.  They  are  incapacitated  as  a 
rule,  but  not  always.  We  often  see  stamping  about  our 
wards  a  man  who  sells  papers.  He  is  far  from  com- 
plete, either  mentally  or  physically,  but  he  still  can 
sell  papers.  He  is  the  only  one  I  have  seen  earning  his 
living.  The  most  important  fact  about  the  treatment 
of  this  disease  is  that  there  is  nothing  to  do.  Any  one 
who  happens  to  be  present  can  feel  perfectly  safe,  be- 
cause there  is  nothing  he  or  any  other  human  being  can 
do.  Nothing  that  we  fail  to  do,  therefore,  can  make 
any  difference. 

The  next  commonest  disease  of  the  brain  is  one  we 
have  already  covered,  syphilitic  disease  of  the  brain  or 
syphilitic  dementia. 

Brain  tumor  is  not  common  or  of  great  importance 
to  social  workers.  I  shall,  therefore,  say  only  a  few 
words  about  it.  It  is  an  incurable  disease  in  practically 
every  case;  very  rarely  a  surgeon  can  get  the  tumor 

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DISEASES  OF  THE  NERVOUS  SYSTEM 

out,  for  as  a  rule  it  fades  off  into  the  brain  substance  so 
that  one  could  not  be  sure  he  had  got  out  the  brain 
tumor  without  taking  out  the  brain.  When  we  think 
of  tumors  we  think  of  elderly  people,  but  brain  tumor 
may  come  at  any  age.  It  produces  headaches — head- 
aches for  which  people  commit  suicide.  Unless  the 
headache  is  dulled  by  a  dulling  of  consciousness  it  may 
be  as  great  a  torture  as  we  ever  have  to  witness.  Some- 
times it  is  so  severe  that  morphine  has  no  effect  on  it. 
With  pain  comes  vertigo  and  vomiting  without  any 
known  cause.  Changes  in  the  eyes  are  almost  invari- 
able, and  are  very  important  for  diagnosis.  The  eye 
specialist  sees,  even  in  early  tumor,  changes  there 
which  may  be  very  important  in  diagnosis.  What  we 
always  hope  about  these  cases  is  that  we  are  wrong  in 
our  diagnosis,  and  that  the  case  is  really  syphilis.  A 
localized  brain  syphilis  gives  the  same  symptoms  and 
may  be  entirely  curable.  Every  case  should  be  treated 
as  if  it  were  syphilis,  and  I  have  seen  some  most  ex- 
traordinary recoveries  in  which  the  patient  had  every 
sign  of  tumor,  but  was  cured  by  anti-syphilitic  treat- 
ment. Those  mistakes  do  not  happen,  so  often 
as  formerly,  now  that  we  have  so  many  tests  for 
syphilis. 

Meningitis,  a  disease  of  the  covering  of  the  brain,  not 
of  the  brain  itself,  has  three  important  forms:  (i)  tu- 
berculous ;  (2)  that  coming  from  disease  of  the  middle 
ear;  and  (3)  the  epidemic,  infectious  form:  —  tubercu- 
lous, aural,  epidemic. 

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Tuberculous  meningitis  is  a  disease  of  babies  and 
young  children,  although  it  does  occasionally  happen 
in  older  people.  It  is  the  common  cause  of  death  from 
tuberculosis  in  young  children.  Young  children  do  not 
die  of  pulmonary  tuberculosis,  but  of  miliary  or  of 
meningeal  tuberculosis.  In  the  child  it  produces  a 
slowly  progressive  dulling  of  consciousness;  the  child 
gets  more  and  more  sleepy;  at  first  the  mother  thinks 
nothing  of  it ;  he  then  begins  to  vomit  without  any  good 
reason,  and  then  begins  to  have  a  squint,  and  then  fe- 
ver —  sleepiness,  vomiting,  squint,  fever,  generally  in 
that  order.  The  diagnosis  is  made  usually  by  a  lumbar 
puncture ;  that  is,  by  putting  a  hollow  needle  between 
the  vertebrae  in  the  lower  back  and  drawing  fluid  from 
the  spinal  cord.  The  spinal  fluid,  which  communicates 
with  the  brain,  shows  tubercle  bacilli  as  well  as  several 
other  characteristic  signs.  The  lungs  do  not  generally 
show  anything.  The  disease  lasts  for  several  weeks, 
sometimes  months,  the  child  gradually  emaciating, 
and  in  about  99.9  per  cent  of  cases  is  fatal.  It  is  not 
absolutely  or  invariably  fatal.  We  used  to  say  that  if 
a  case  got  well  it  proved  that  the  diagnosis  was  wrong, 
but  recently  the  bacilli  have  been  demonstrated  in  the 
spinal  fluid  of  cases  which  got  well.  It  can  come 
through  the  bovine  type  of  bacillus,  cow  tuberculosis, 
in  perhaps  one  case  in  twenty-five;  much  more  often 
by  the  ordinary  method  of  taking  in  the  bacilli  from 
other  human  beings. 


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Questions  and  Answers 

Q.  Can  it  come  from  a  pulmonary  tuberculosis? 

A.  Yes;  it  is  the  final  stage  of  pulmonary  tuberculosis  in  a 
small  percentage,  especially  of  the  rarer  adult  cases. 

Q.  How  long  does  it  take  to  develop? 

A.  At  first  a  child  may  seem  just  a  little  more  sleepy  than 
usual.  Within  a  week  or  so  we  are  sure  that  something  is 
wrong;  but  the  child  may  simply  seem  listless  and  sleepy. 
There  are  a  great  many  wrong  diagnoses  because  people  do 
not  think  the  child  can  have  any  such  terrible  disease  —  he 
does  not  seem  sick  enough. 

j_  The  second  form  of  meningitis,  more  cheerful  be- 
cause curable,  is  that  which  comes  from  the  middle 
ear.  The  chief  reason  for  being  greatly  interested  in 
every  child  who  has  a  running  ear,  in  all  cases  of  otitis 
media,  is  the  possibility  of  meningitis  or  brain  abscess, 
and  the  possibility  of  preventing  that.  The  reason  why 
we  operate  on  so  many  "  mastoid  cases  "  —  i.e.,  to  clean 
out  the  mastoid  bone  behind  the  ear  —  is  that  only 
the  thickness  of  a  piece  of  cloth  separates  that  portion 
of  the  skull  from  the  brain.  We  are  always  afraid  that 
the  infection  will  go  through  and  produce  meningitis. 
As  long  as  otitis  media  has  perfectly  free  drainage,  so 
long  as  there  is  no  involvement  of  the  mastoid,  we  do 
not  feel  alarm.  Even  after  meningitis  has  begun  cases 
may  be  saved  by  prompt  operation,  getting  the  pus 
out.  This  disease  often  causes  death  in  babies,  and 
is  often  wholly  unsuspected.  The  child  may  not  put 
its  hand  to  its  ear  at  all.  There  may  be  no  discharge. 

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The  child  may  have  stomach  symptoms  only  —  not  a 
thing  to  draw  our  attention  to  the  ears.  Any  child  that 
is  sick  and  not  doing  well  should  have  an  expert  exami- 
nation of  the  ears.  It  does  not  make  any  difference 
what  a  child  has;  if  he  is  sick  and  not  doing  well,  look 
after  his  ears. 

Last  week  I  attended  an  autopsy  on  a  baby.  During 
life  our  attention  had  been  centred  on  the  chest  and 
abdomen,  yet  the  autopsy  showed  nothing  wrong 
there  ;  it  was  a  case  of  meningitis  from  ear  disease.  It  is 
always  a  social  worker's  duty  to  see  whether  a  sick 
baby's  ears  have  been  examined  and  if  not  whether 
they  cannot  be. 

Questions  and  Answers 

Q.  Is  ordinary  abscess  of  the  Eustachian  tube  tubercu- 
lous? 

A.  Any  inflammation  in  the  throat  can  spread  from  the 
Eustachian  tube  to  the  middle  ear  and  be  dangerous  in  that 
way.  The  ordinary  causes  of  colds,  the  streptococcus,  usu- 
ally causes  the  inflammation. 

Q.  What  can  you  do  to  keep  a  baby  from  getting  it? 
Extreme  cleanliness? 

A.  Generally  that  means  shutting  the  door  after  the  horse 
has  been  gone  some  time.  I  do  not  know  any  way.  What 
we  notice  is  that  the  children  in  poor  families,  poorly  nour- 
ished, poorly  cared  for,  have  a  great  deal  more  of  this  disease 
than  the  children  of  well-cared-for  families.  The  best  thing 
is  to  try  to  have  the  children  well  cared  for  and  well  nour- 
ished. I  do  not  believe  local  care  has  much  effect. 


third  form  of  meningitis  is  the  epidemic,  so- 
called  cerebro-spinal  meningitis.   Really  all  meningitis 

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DISEASES  OF  THE  NERVOUS  SYSTEM 

is  cerebro-spinal  —  that  word  does  not  mean  much ; 
the  connection  between  brain  and  spinal  cord  is  such 
that  if  we  have  disease  in  the  brain  we  almost  always 
have  it  in  the  spine.  This  disease  is  due  to  a  distinct 
organism,  as  definite  as  the  tubercle  bacillus,  and  one 
which  we  have  of  late  years  a  reasonable  amount  of 
power  to  cure.  I  think  it  is  interesting  to  remember 
how  this  came  about.  Some  years  ago  Mr.  Rockefeller 
thought  he  would  like  to  do  a  good  work  and  he  hired 
a  man  to  invent  a  cure  —  a  man  to  find  a  cure  for  a 
disease.  People  laughed  at  the  idea  and  said:  "That 
means  finding  a  genius ;  you  cannot  hire  a  man  to  invent 
a  cure  for  disease."  But  Mr.  Rockefeller  kept  right 
on,  and  after  looking  around  decided  that  Dr.  Flexner 
was  the  most  promising  man  in  the  United  States,  and 
paid  him  a  good  salary  to  do  nothing  in  the  world 
but  try  to  discover  something  new.  At  this  there  was 
loud  laughter,  but  it  was  not  two  years  before  he 
had  worked  out  an  anti-meningitis  serum  which  has 
changed  the  mortality  of  this  disease  from  seventy- 
five  to  twenty-five  per  cent.  Now  only  one  quarter 
die,  and  if  we  get  them  early  enough,  less  than  one 
quarter  die.  It  is  now  a  disease  about  as  bad  as  pneu- 
monia; not  much  worse,  provided  we  give  the  treat- 
ment. Dr.  Flexner  cultivated  the  bacillus,  worked  out 
an  anti-serum,  like  the  anti-diphtheritic  serum,  and 
supplied  it  free  to  whosoever  would  furnish  proof  that 
the  patient  had  the  disease.  The  procedure  is  first  to 
tap  the  spinal  cord,  catch  the  organism  in  the  fluid, 

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recognize  it,  and  then  inject  into  the  spinal  fluid  the 
anti-meningitis  serum.  This  treatment  is  one  of  the 
most  satisfactory  examples  of  putting  the  cure  right 
on  the  spot.  Patients  always  want  something  put  on 
the  spot  —  on  the  head  for  headache,  on  the  foot  for 
foot-ache  —  and  we  cannot  do  it.  But  here  is  a  case 
where  we  can  put  the  medicine  into  the  brain  and 
spinal  cord,  introduce  it  directly,  and  have  it  run  about 
through  the  whole  system.  The  serum  is  of  no  use  if 
put  into  the  stomach  or  into  the  veins  or  under  the 
skin ;  it  is  of  use  only  if  put  where  the  trouble  is.  The 
same  is  true  of  the  anti-tetanic  serum,  which  is  useless 
in  tetanus  unless  it  is  put  right  into  the  brain  or  spinal 
cord. 

This  disease  is  a  rare  one.  We  have  not  had  a  bad 
epidemic  now  since  1897.  Since  then  there  have  been 
very  few  cases  in  Boston.  This  is  one  of  the  diseases 
which  is  called  "spotted  fever."  There  is  no  such  thing 
as  "spotted  fever,"  but  meningitis  is  one  of  the  diseases 
which  has  received  that  name.  Typhus  is  another. 

Q.  How  is  the  infection  carried? 

A.  I  do  not  think  it  is  known,  but  the  belief  is  that  it  is 
carried  by  the  breath  and  up  the  nasal  cavities,  which  com- 
municate with  the  brain,  through  the  ethmoid  bone.  The 
bacillus  is  found  in  the  nasal  cavity  sometimes;  presumably 
that  is  how  it  gets  in,  but  we  do  not  know  it. 


CHAPTER  XI 

DISEASES  OF  THE  NERVOUS  SYSTEM  (CONTINUED) 

Diseases  of  the  Spinal  Cord 

THE  spinal  cord  is  the  prolongation  of  the  brain  down 
through  the  backbone,  really  a  piece  of  the  brain 
stretched  out  or  pulled  out  in  that  direction.  It  can 
perform  a  great  many  of  the  functions  for  which  we 
ordinarily  suppose  a  brain  is  necessary.  An  animal  de- 
prived of  its  brain  can  eat  and  run  about  and  do  a 
good  many  things  provided  it  has  its  spinal  cord;  it 
can  also  get  angry  or  at  least  show  the  ordinary  signs 
of  wrath. 

The  most  important  of  the  diseases  of  the  spinal  cord 
is  tabes,  syphilis  of  the  spinal  cord.  Tabes  is  short  for 
tabes  dor  sails,  or  back  sickness,  a  very  vague  term,  the 
other  phrase  used  being  locomotor  ataxia.  That  is  not 
good  either,  because  it  means  that  you  cannot  walk, 
whereas  some  of  these  people  can  walk  perfectly. 
Spinal  syphilis  is  the  only  proper  term  for  it.  It  is,  of 
course,  very  common  and  as  preventable  as  syphilis, 
but  not  as  curable  as  many  other  forms  of  syphilis. 
Until  within  a  few  years  we  have  said  that  it  was  en- 
tirely incurable,  but  most  of  us  now  believe  that  it  can 
be  helped  a  good  deal  by  the  intra-spinal  administra- 
tion of  salvarsan  in  blood  serum. 

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Tabes  belongs  in  two  groups,  the  "high"  and  the 
"low."  The  high  affects  the  eyes,  and  the  eyes  only  as 
a  rule;  the  person  becomes  blind  from  atrophy  of  the 
nerve  which  leads  to  the  eye  and  of  the  corresponding 
portion  of  the  spinal  cord.  It  is  an  incurable,  a  long- 
lasting  blindness  following  syphilis.  The  other,  com- 
moner form,  low  tabes,  presents  itself  most  often  with 
pains  in  the  legs.  These  pains,  if  we  have  a  chance  to 
cross-question  a  patient,  turn  out  to  be  different  in 
most  cases  from  any  other  pains  that  we  see.  This 
particular  pain  in  the  legs  I  cannot  say  that  I  have  ever 
seen  except  in  this  disease.  The  textbooks  speak  of 
them  as  "lightning  pains";  also  as  "lancinating"  or 
darting  pains,  pain  that  goes  through  one  like  "a 
streak  of  lightning,"  shoots  up  or  down  the  leg  and 
within  a  second  or  a  fraction  of  a  second  is  gone.  It 
may  be  in  the  arm  or  trunk,  but  not  nearly  so  often. 
It  is  so  brief  that  one  would  think  it  would  not  be  very 
troublesome,  but  if  those  things  occur  every  few  sec- 
onds it  is  enough  to  burden  the  mind  a  good  deal. 
"Lightning  pains"  are  often  the  first  thing  complained 
of.  Another  symptom  is  a  queer  type  of  stomach 
trouble,  known  technically  as  gastric  crises.  This  is  a 
recurrent  paroxysm  of  vomiting  and  pain  lasting 
twenty- four  hours  or  a  day  or  two,  and  then  leaving  the 
individual  entirely  for  days  or  weeks.  It  is  mistaken 
for  all  sorts  of  things.  Cases  of  tabes  are  often  oper- 
ated on  for  peritonitis,  gall-bladder  disease,  or  stom- 
ach ulcer,  because  the  pains  are  in  the  stomach.  This 

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DISEASES  OF  THE  NERVOUS  SYSTEM 

mistake  is  nowadays  inexcusable  because  we  can 
always  recognize  tabes  if  we  test  for  it;  but  it  is  a  mis- 
take that  has  happened  in  most  hospitals  a  great  many 
tjmes.  Next  to  these  two  symptoms  comes  weakness 
in  the  legs  and  then  troubles  with  the  bladder,  diffi- 
culty in  controlling  the  flow  of  urine.  The  earliest  and 
most  frequent  sign  by  which  the  physician  recognizes 
this  disease  is  the  loss  of  knee-jerks. 

I  do  not  see  why  any  layman  should  not  learn  to 
take  knee-jerks.  There  is  no  mystery  about  it,  and  it 
might  turn  out  very  convenient.  The  simplest  way, 
and  the  way  in  which  we  ordinarily  proceed,  is  to  have 
the  knees  crossed  and  then  to  tap  below  the  patella. 
But  although  the  usual  way,  that  is  not  the  best.  Peo- 
ple often  hold  the  leg  so  very  stiff  that  we  cannot  get 
the  jerk.  The  better  position  is  with  the  feet  side  by 
side,  when  a  little  tap  will  make  the  thigh  muscle 
twitch  under  the  left  hand  laid  on  it.  The  whole  knack 
is  to  know  where  to  strike,  and  that  is  quite  simple. 
We  feel  for  the  lower  edge  of  the  knee-pan  where  it 
comes  to  a  point  just  in  front  of  the  knee  and  just 
before  it  merges  into  a  tendon.  Then  hit  the  tendon. 

In  tabes  the  knee-jerks  are  absent  in  the  vast  ma- 
jority of  cases.  There  is  only  one  other  disease  which 
makes  them  absent  in  any  considerable  number  of 
cases,  and  that  is  alcoholic  neuritis.  There  is  about  one 
chance  in  ten  that  it  is  alcoholic  neuritis. 

The  other  characteristic  change  is  in  the  pupil, 
which  ordinarily  contracts  when  light  is  directed  at  it 

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from  a  small  pocket-lamp.  The  tabetic  pupil  does  not 
budge,  stays  exactly  the  same  size.  That  test,  again,  I 
cannot  imagine  why  any  intelligent  person  should  not 
learn  to  make. 

I  think  that  we  ought  all  to  be  able  to  take  tempera- 
tures and  feel  pulses.  The  doctor  whom  we  want  is 
often  not  available,  and  it  is  often  important  to  know 
how  to  steer  the  patient.  I  think  anything  that  does 
no  harm  and  is  easy  to  learn,  and  gives  important  in- 
formation, ought  to  be  acquired  by  the  ordinary  citi- 
zen. In  old  times  it  was  thought  a  very  serious  matter 
to  take  temperatures.  My  uncle  used  to  recall  the  time 
when  in  the  Massachusetts  General  Hospital  no  nurse 
was  allowed  to  take  a  temperature;  it  was  too  serious 
and  delicate  a  matter.  The  doctor  had  to  do  that. 

After  the  symptoms  mentioned,  lightning  pains,  gas- 
tric crises,  weakness  of  the  legs,  and  bladder  symptoms, 
comes  the  train  of  symptoms  whereby  the  term  locomo- 
tor  ataxia  takes  its  rise.  When  a  tabetic  loses  control 
of  his  muscles  he  does  not  lose  strength ;  he  thinks  his 
muscles  are  weak,  but  they  are  not.  The  truth  is  that 
he  does  not  know  how  to  control  his  legs ;  he  does  not 
know  where  his  feet  are.  We  control  ourselves  by  the 
sense  of  the  ground  under  our  feet ;  he  does  not  know 
when  his  feet  touch  the  ground  and  when  they  go  off. 
He  sprawls  and  stumbles  because  he  has  lost  the  sense 
of  distance  and  position,  though  not  the  sense  of  pain. 
He  can  feel  a  pin-prick. 

Still  later,  in  the  stages  which  we  do  not  ordinarily 

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DISEASES  OF  THE  NERVOUS  SYSTEM 

see  because  he  is  not  able  to  go  about,  he  becomes  par- 
alyzed —  that  is,  always  supposing  that  the  medical 
treatment  that  I  have  spoken  of  is  not  available  or  is 
not  carried  out.  In  early  stages  we  should  try  to  have 
this  carried  out,  but  it  takes  months  and  it  costs  a  good 
deal  for  somebody.  The  spine  has  to  be  punctured 
again  and  again ;  the  treatment  has  to  be  given  into  the 
spinal  cord,  not  once  or  twice  but  many  times;  and  no 
improvement  can  be  expected  until  several  months 
have  passed.  Yet  with  a  fearful,  progressive  disease  like 
this  it  is  our  duty  to  urge  it,  I  think.  Lumbar  punc- 
ture is  ordinarily  painful,  but  not  excessively  so.  Some 
patients  have  pain  afterwards  in  the  puncture  or  in  the 
head  or  in  the  legs,  especially  patients  to  whom  it  is 
done  in  an  out-patient  department  and  who  do  not  lie 
in  bed.  They  have  pain  and  usually  severe  headache. 
But  in  a  disease  for  which  we  have  no  other  treatment 
to  offer,  we  should  urge  a  person  to  bear  the  pain.  The 
puncture  is  made  on  the  level  of  the  hip  bone ;  we  carry 
the  line  around  from  hip  to  hip,  and  where  it  crosses  the 
backbone,  there  the  puncture  is  made.  We  reach  the 
spinal  canal,  which  communicates  with  the  brain,  and 
put  in  the  medicine  there. 

Questions  and  Answers 

Q.  Can  the  locomotor  ataxia  patient  be  taught  to  walk? 

A.  Yes;  a  certain  number  of  them,  even  without  intra- 
spinous  treatment,  can  get  over  that  one  symptom.  A  man 
who  does  not  know  where  his  legs  are  can  learn  (provided 
he  has  an  unusual  amount  of  stick- to-it-iveness) ,  without 

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any  treatment  at  all  except  walking  up  and  down  a  chalk- 
line  until  he  can  do  it  accurately. 

Q.  Does  a  conquest  of  the  difficulty  in  walking  interfere 
at  all  with  the  progress  of  the  disease? 

A.  No;  the  disease  goes  on  just  the  same.  For  practical 
purposes  supervision  helps  toward  this  reeducation  of  the 
leg  muscles.  It  is  not  complicated;  there  is  no  difficulty 
about  it,  if  a  person  has  perseverance  enough;  but  most 
people  won't  do  it  by  themselves. 

A.  Does  locomotor  ataxia  result  from  anything  else  than 
syphilis? 

A.  Not  in  my  opinion,  nor  in  the  opinion  of  most  physi- 
cians at  the  present  time.  Locomotor  ataxia  is  never  in- 
herited nor  due  to  anything  but  syphilis. 

Q.  When  a  person  has  syphilis  in  the  form  of  locomotor 
ataxia,  may  it  be  inherited  by  his  children? 

A.  No.  He  may  have  given  syphilis  to  his  wife  and  chil- 
dren in  some  previous  stage  of  the  disease,  but  at  the  stage 
of  tabes  it  is  a  danger  to  no  one  except  the  patient  himself. 
A  patient  may  develop  it  in  youth;  syphilis  may  develop 
so  fast  that  the  tabes  appear  even  in  youth. 

Q.  Should  the  family  of  a  case  of  this  sort  always  be  ex- 
amined ? 

A.  Yes,  I  think  so. 

The  outlook  and  treatment  of  tabes  until  within  the 
past  two  years  has  been  pretty  hopeless,  and  it  is  be- 
cause we  do  not  now  so  consider  it,  and  because  the 
course  of  treatment  that  we  advise  takes  so  long  and 
costs  so  much,  that  I  feel  that  we  all  ought  to  be  con- 
versant of  what  is  ordinarily  done. 

Until  we  realized  that  we  could  go  straight  to  the 
place  where  the  trouble  is  in  the  spinal  cord,  we  had 
very  little  if  any  control  of  the  disease.  The  intraspinal 

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DISEASES  OF  THE   NERVOUS  SYSTEM 

injection  of  salvarsan  in  its  pure  state  is  very  danger- 
ous, but  if  the  patient  is  first  given  salvarsan  into  a 
vein  in  the  ordinary  way,  is  then  bled,  and  his  own 
blood  serum  put  back  into  his  spinal  cord,  that  does 
good.  It  does  not  do  good  in  a  single  treatment,  nor 
often  within  a  single  month.  The  cases  that  have  the 
best  results  have  been  treated  for  from  half  a  year  to  a 
year.  The  disease  may  cling  to  a  patient  for  thirty  or 
forty  years  and  go  slowly  but  steadily  on  from  bad 
to  worse,  so  the  fact  that  the  treatment  is  long  and 
tedious  is  not  a  sufficient  reason  for  not  doing  it. 

The  treatment,  already  described,  intraspinous  in- 
jection of  salvarsanized  serum,  is  carried  out  in  all  the 
larger  cities  now;  the  patient  is  given  injections,  at 
intervals  of  from  two  or  three  weeks  to  a  month  or  two, 
over  a  long  period.  Sometimes  mercury  is  used  in  the 
same  way;  one  cannot  put  salvarsan  directly  into  the 
spinal  cord  without  great  danger,  and  there  have  been 
deaths  from  this  attempt.  But  when  the  drug  is  put 
into  the  blood  and  the  blood  combined  with  it,  and  that 
blood  put  into  the  spinal  cord,  one  can  do  it  without 
harm.  When  we  urge  this  treatment  upon  patients, 
we  must  make  it  clear  that  they  cannot  expect  any 
results  within  a  few  weeks,  that  they  have  got  to  go  to 
the  doctor  a  great  many  times,  that  their  home  doctor 
usually  cannot  do  it  —  very  few  doctors  are  willing  to 
take  the  trouble  and  run  the  risks.  All  this  has  to  be 
explained  to  the  patient,  but  if  it  is  explained  and  still 
he  wants  it  done,  we  can  and  we  should  exert  the 

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amount  of  pressure  that  laymen  or  social  workers  can 
exert,  because  they  are  looked  upon  as  being  unpreju- 
diced. The  doctor  may  be  suspected,  often  falsely,  of 
favoring  the  treatment  because  he  is  fond  of  doing  it  or 
because  he  profits  by  it. 

After  this  treatment  I  have  seen  men  lose  their  pain, 
get  back  their  control  of  the  bladder,  become  able  to 
walk.  The  objective  evidence  of  the  disease,  as  we  find 
it  in  the  spinal  cord  itself  through  spinal  puncture  (the 
diseased  condition  of  the  spinal  fluid),  decreases  par- 
allel to  the  improvement  of  the  patient.  We  are  com- 
forted by  that  because  in  a  disease  which  lasts  so  long 
the  effect  of  suggestion  on  symptoms  is  so  great.  But 
suggestion  won't  change  the  number  of  cells  in  the 
spinal  cord  or  make  the  positive  Wassermann  become 
negative.  Because  of  this  objective  improvement  we 
have  more  confidence  than  we  otherwise  should  have 
that  the  treatment  is  of  some  use. 

Most  of  the  other  diseases  of  the  spinal  cord  aside 
from  tabes  have  the  same  cause,  —  that  is,  they  are 
mostly  syphilitic,  —  and  I  do  not  think  much  needs 
to  be  said  of  them.  They  may  improve  under  anti- 
syphilitic  treatment;  they  are  apt  to  improve  more 
than  tabes  does.  There  are  acute  forms  of  syphilis  of 
the  spinal  cord  which  produce  a  sudden  and  complete 
paralysis,  and  yield  very  thoroughly  to  anti-syphilitic 
treatment. 

One  form,  which  we  do  not  know  to  be  syphilitic,  is 
generally  spoken  of  as  spastic  spinal  paralysis.  Most 

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DISEASES  OF  THE  NERVOUS  SYSTEM 

of  us  have  seen  examples  of  that  on  the  street.  The 
gait  is  characteristic;  the  man  cannot  lift  his  feet.  He 
scuffs  and  drags  his  feet  along,  owing  to  the  spasm  of 
his  muscle.  There  is  no  weakness,  the  muscles  are 
strong,  but  they  are  in  a  constant  state  of  tension. 
This  is,  so  far  as  I  know,  incurable,  because  the  only 
hold  we  have  on  the  other  forms,  the  anti-syphilitic 
treatment,  we  have  not  in  this.  The  only  thing  to  do 
is  to  arrange  braces,  which  sometimes  make  it  a  little 
easier  for  the  individual  to  get  along,  by  giving  him 
some  relief  in  walking. 

Then  there  remains  poliomyelitis,  which  is  chiefly  a 
disease  of  the  spinal  cord,  although  we  do  not  often 
think  of  it  in  that  way.  This  is  infantile  paralysis,  the 
paralysis  of  which  we  have  heard  so  much  in  late  years, 
which  seems  to  be  epidemic,  the  cause  of  which  we 
know  something  about,  but  the  method  of  transmis- 
sion of  which  we  still  do  not  know.  Spinal  paralysis  of 
children,  infantile  paralysis,  and  poliomyelitis l  are  all 
the  same. 

It  was  not  until  within  a  few  years  that  we  had  any 
idea  that  this  was  a  germ  disease ;  its  tendency  to  ru«' 
in  epidemics  somehow  had  not  been  noticed.  It  is, 
however,  an  infectious  disease,  though  not  contagious 
in  the  ordinary  way.  The  curious  thing  is  that  as  we 
go  through  a  village  we  find  one  case  in  a  house,  rarely 

1  Polio  my  el  itis:  itis  means  inflammation;  myel  means  spinal  cord; 
polio  means  white  —  the  inflammation  of  the  white  portion  of  the  spinal 
cord. 

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two  cases  in  a  house.1  This  is  something  which  nobody 
has  so  far  been  able  to  understand.  Sometimes  it  has 
been  noticed  that  it  seemed  to  go  down  one  side  of  a 
street,  but  on  the  whole  this  seems  to  be  not  more  than 
a  coincidence.  The  cases  come  in  groups.  The  New 
York  epidemic  of  1916  is  the  largest  on  record,  but  in 
Boston  we  had  over  one  thousand  cases  a  few  years 
ago  and  there  have  been  extensive  epidemics  in  Scan- 
dinavia and  other  places.  Adults  are  very  rarely  af- 
fected ;  if  an  adult  gets  it  we  are  always  doubtful  of  the 
diagnosis.  In  children  it  begins  usually  with  symp- 
toms of  a  fever  and  often  with  brain  symptoms  like 
those  of  meningitis;  2  the  child  feels  hot;  we  find  a 
temperature ;  he  is  headachy,  listless,  cries,  and  vomits; 
but  often  nothing  is  thought  of  the  matter  until,  usu- 
ally the  next  day,  the  paralysis  is  noted.  The  paralysis 
is  most  apt  to  affect  one  leg  or  some  of  the  muscles  of 
one  leg.  Luckily  that  is  the  commonest  thing ;  it  may 
affect  both  legs,  both  legs  and  both  arms,  or  it  may 
affect  every  muscle  in  the  body  and  be  fatal  —  fatal 
by  affecting  the  muscles  of  the  breathing  apparatus, 
getting  hold  of  the  diaphragm  and  making  it  impos- 
sible for  the  person  to  breathe.  Many  recover  without 
paralysis;  others  with  a  paralysis  left  which  practi- 
cally never  gets  well;  it  gets  better,  the  amount  of 
improvement  differing  in  different  cases,  but  it  almost 

1  Out  of  the  first  7000  cases  in  the  New  York  epidemic  of  1916, 
6748  were  in  different  families. 

2  See  page  260. 

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DISEASES  OF  THE  NERVOUS  SYSTEM 

never  gets  well.   I  have  known  it  to  get  so  nearly  well  1 
that  the  boy  who  had  it  grew  up  to  be  an  athlete  and 
rowed  stroke  on  a  Harvard  crew. 

The  results  of  poliomyelitis  have  come  to  be  the 
province  of  the  orthopedist  because  the  apparatus  and 
the  operation  upon  the  tendons  (which  often  have  to 
be  transplanted)  are  more  properly  in  the  orthopedist's 
province.  Apparatus  is  used  for  supporting  the  para- 
lyzed leg,  especially  in  the  early  stages.  We  generally 
advise  massage  and  local  treatment  of  that  sort,  to 
keep  up  the  nutrition  of  the  muscles,  but  not  a  great 
deal  is  accomplished  in  that  way. 

It  is  a  long,  partially  crippling  injury,  with  a  need  for 
vocational  steering  in  relation  to  the  patient's  subse- 
quent work,  a  need  for  relief  often  when  it  happens  to 
an  adult  who  has  been  working,  and  for  help  with  the 
expensive  apparatus.  It  is  the  commonest  disease  of 
the  spinal  cord  that  we  see,  except,  perhaps,  tabes. 

Questions  and  Answers 

Q.  Is  it  known  to  follow  any  other  children's  disease? 

A.  No,  I  think  not. 

Q.  Does  the  limb  shrink? 

A.  Yes ;  the  limb  atrophies  always  —  the  amount  of 
shrinking  depends  upon  how  many  muscles  are  involved. 

Q.  Does  recovery  depend  on  the  severity  of  the  attack? 

A.  Yes.  The  amount  of  motion  recovered  in  paralyzed 
children  depends  on  the  extent  and  severity  of  the  original 
attack. 

Q.  Is  the  brain  affected? 

A.  The  brain  is  usually  not  affected.  As  a  rule  the  disease 

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vents  itself  chiefly  or  wholly  on  the  spinal  cord,  and  does 
not  affect  any  other  part.  It  is  not  painful  except  in  the  ear- 
liest stages. 

Q.  Is  there  an  operation  for  it? 

A.  Yes;  one  of  the  operations  done  is  to  transplant  the 
tendon  from  a  sound  muscle  into  the  paralyzed  one;  in 
some  cases  that  has  had  brilliant  results. 

Q.  Are  nervous  children  more  apt  to  have  this? 

A.  No,  not  so  far  as  any  one  knows. 

It  does  not  affect  the  speech.  There  was  a  time  when 
it  was  believed  that  it  was  transmitted  by  the  fly,  and 
that  is  not  absolutely  disproved  yet,  but  it  is  not  the 
prevailing  belief  at  the  present  time,  which  is  that  this 
is  given  the  way  colds  are  given,  from  the  throat  and 
nose.  This,  like  all  the  theories  about  its  mode  of 
transmission  seems  to  me  improbable.  The  only  ani- 
mal who  can  be  made  to  take  it  is  one  species  of  mon- 
key, and  at  the  Rockefeller  Institute  in  New  York  a 
great  deal  of  fruitless  experimental  work  has  been  done 
upon  them  in  hope  of  finding  some  way  to  control  the 
disease. 

Diseases  of  the  Peripheral  Nerves 

The  one  important  disease  of  the  peripheral  nerves 
is  neuritis.  Neuritis  is  a  very  popular  ailment,  but  as  a 
matter  of  fact  it  is  a  rare  disease.  One  can  practise  a 
long  time  and  never  see  the  disease,  but  one  hears  of 
a  great  many  diagnoses,  especially  upon  the  lips  of  his 
patients.  "Neuritis"  sounds  better  than  "neuralgia," 
but  it  would  not  sound  so  well  if  people  knew  that  it  is 

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DISEASES  OF  THE   NERVOUS  SYSTEM 

generally  due  to  alcohol.  Alcoholic  neuritis  is  the  most 
usual  form.  The  alcohol  circulating  in  the  blood  gets 
hold  of  the  nerve  fibres  and  degenerates  them  so  that 
we  get  weakness  and  paralysis  chiefly  of  the  legs,  often 
with  pain  and  numbness,  and  sometimes  with  swell- 
ing. The  most  important  thing  to  know  about  this  is 
that  it  gets  entirely  well  provided  the  individual  mends 
his  ways.  It  is  unlike  diseases  of  the  spinal  cord,  which 
very  rarely  get  wholly  well.  These  nerve  diseases  out- 
side the  cord  show  an  extraordinary  capacity  to  heal. 
You  can  say  with  perfect  confidence,  "Yes,  if  you  will 
stop  drinking  you  can  get  entirely  well." 

When  I  was  speaking  of  tabes  I  spoke  of  the  loss  of 
knee-jerks  in  that  disease.  Alcoholic  neuritis  is  about 
the  only  other  disease  in  which  a  person  loses  both 
knee-jerks. 

Occasionally  we  see  a  pressure  neuritis,  a  neuritis 
from  great  pressure  on  the  nerve,  sometimes  called  the 
"Saturday  night  paralysis."  It  is  quite  a  picturesque 
disease.  A  gentleman  dines  a  little  too  well  and  goes  to 
sleep  upon  the  Common ;  he  puts  his  arm  over  the  back 
of  the  settee  and  goes  to  sleep  with  his  head  on  his  arm. 
As  soon  as  the  arm  begins  to  get  uncomfortable,  the 
average  sober  person  would  wake  up  and  shift  his  posi- 
tion, but  the  alcoholic  does  not  know  anything  until 
next  morning.  Then  he  wakes  to  find  his  arm  para- 
lyzed, and  on  Monday  mornings  we  used  to  have  a 
group  of  these  patients  in  the  out-patient  department 
of  the  Massachusetts  General  Hospital.  The  moral 

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effect  of  finding  what  has  happened  to  them  as  a  result 
of  their  habits  is  often  very  salutary.  This,  like  the 
other  forms  of  neuritis,  gets  wholly  well  in  the  majority 
of  cases ;  in  the  course  of  time  the  man  recovers  full 
use  of  his  muscles. 

Q.  Can  neuritis  come  from  injury? 

A.  Yes;  the  type  just  described  comes  from  injury.  An- 
other type  results  from  bad  wounds  or  blows  or  crushes  of 
the  arm.  Any  great  strain  or  tearing  upon  the  arm  some- 
times brings  about  neuritis.  I  remember  a  man  who  was 
riding  one  horse  and  leading  another;  the  other  horse  tried 
to  get  away  and  in  trying  to  hold  him  the  rider  tore  his 
brachial  plexus  of  nerves  and  had  neuritis. 

Do  not  believe  that  people  have  neuritis  merely 
because  they  have  pains  in  the  arms.  These  pains  are 
very  common,  and  in  the  vast  majority  of  cases  there 
is  no  reason  to  suppose  that  there  is  any  neuritis.  The 
great  thing  about  neuritis  is  that  it  gets  well  and  that  it 
is  rare  and  that  treatment  has  very  little  to  do  with  it. 

The  difference  between  neuritis  and  neuralgia  is 
easily  made  through  electrical  tests  given  by  any  neu- 
rologist or  any  neurological  department.  These  tell  us 
whether  the  nerve  is  affected  or  not.  When  the  nerve 
is  actually  affected,  recovery  is  usually  much  slower 
than  when  we  are  dealing  merely  with  a  pain,  neu- 
ralgia, without  organic  basis  that  we  know. 

There  are  certain  other  diseases  of  the  nervous  sys- 
tem that  must  be  named,  although  we  do  not  know 

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DISEASES  OF  THE  NERVOUS  SYSTEM 

their  organic  basis.  The  most  important  is  epilepsy,  a 
disease  characterized  by  fits  of  unknown  origin.  There 
are  a  great  many  fits  whose  cause  we  know ;  the  patient 
with  Bright's  disease  has  fits  from  self-poisoning  — 
uremia;  the  patient  with  syphilis  or  paresis  has  fits 
from  the  actual  disease  in  his  brain.  But  the  epileptic 
has  fits,  and  after  death  we  often  can  find  nothing 
wrong  in  the  brain. 

There  is  something  more  to  be  said  in  description  of 
the  fits.  The  epileptic  fit  differs  from  the  hysterical 
attack,  and  the  main  differences  should  be  known  by 
every  one,  I  think.  The  epi*  ptic  patient  generally  falls 
in  his  fit,  and  that  is  in  contrast  with  hysteria  and  many 
other  seizures  in  which  people  generally  do  not  fall, 
but  get  to  a  chair  or  step.  The  characteristic  thing 
about  an  epileptic  is  that  he  first  stiffens  out  rigid  and 
then  falls  so  that  his  head  is  the  first  thing  that  strikes. 
He  is  very  apt  to  hurt  himself.  The  hysteric  never 
hurts  himself  by  falling ;  he  has  enough  warning  of  what 
is  coming  on  to  guard  himself.  The  epileptic  attack 
generally  begins  with  a  cry,  a  shout,  or  scream  of  which 
the  individual  is  practically  never  aware;  he  hears 
from  his  friends  that  he  has  cried  out.  That  again  is 
in  contrast  with  hysteria.  The  epileptic  falls  and  re- 
mains absolutely  unconscious.  The  hysterical  patient 
can  be  aroused  by  proper  stimulation,  sometimes  ther- 
mic, sometimes  psychical.  The  epileptic  cannot  be 
aroused  by  anything  whatsoever.  He  is  unconscious 
for  a  few  minutes,  never  over  an  hour.  For  a  few  min- 

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utes,  as  a  rule,  during  the  unconsciousness,  he  has 
shaking  movements  of  the  arms  and  legs,  alternating 
contraction  and  extension,  so  that  the  arms  and  legs 
"work."  He  also  opens  and  shuts  his  jaws,  and 
thereby  bites  his  ^tongue.  The  first  aid  consists  in 
putting  something  between  the  teeth  so  that  the  indi- 
vidual cannot  bite  his  tongue;  it  saves  a  sore  tongue 
afterwards.  These  patients  look  very  ill.  It  is  a  very 
terrible  thing  to  see  the  first  time  one  sees  it,  but  no- 
body ever  dies  in  this  type  of  fit.  After  a  few  minutes 
the  epileptic  relaxes  and  remains  in  a  heavy,  sleepy 
condition,  usually  for  some  hours  after  it.  He  may 
vomit  at  the  end.  He  is  very  apt  to  pass  urine  during 
an  attack,  which  a  hysterical  patient  never  does. 

The  French  terms,  grand  mal  and  petit  mal,  have 
been  adopted  pretty  much  all  over  the  world.  What  I 
have  just  described  is  grand  mal,  the  big  attack.  I 
must  add  that  one  of  the  most  important  things  about 
the  epileptic  is  the  various  queer  things  which  he  may 
do  just  after  an  attack.  He  is  often  not  right  in  his 
mind  for  some  time  after  an  attack;  that  is,  for  some 
hours,  occasionally  a  day.  This  may  show  itself  merely 
in  his  being  sleepy,  stupid,  in  being  rather  cross  and 
cranky,  or  it  may  show  itself  in  criminal  acts  of  which 
the  individual  has  no  knowledge  and  for  which  he  is 
not  responsible  —  a  very  important  medico-legal  as- 
pect of  this  disease.  One  of  Dr.  Healy's  most  inter- 
esting chapters  1  is  devoted  to  the  criminal  or  epileptic 
1  William  Healy,  The  Individual  Delinquent.  Boston,  1915. 
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DISEASES  OF  THE  NERVOUS  SYSTEM 

type  whose  misdeeds  are  really  an  effect  of  his  epilepsy, 
and  for  which  he  is  not  in  any  way  responsible.  If  he 
has  his  fit  away  from  home,  on  the  street,  or  in  the 
country,  he  will  get  up  and  wander  off  somewhere, 
will  have  no  idea  where  he  is  wandering  to,  and  will 
sometimes  get  lost. 

Petit  mal,  the  other  form  of  epilepsy,  may  precede 
but  generally  accompanies  grand  mal,  the  slighter  at- 
tacks coming  in  between  the  more  severe  ones.  They 
are  much  more  frequent,  may  come  a  dozen  times  a 
day,  and  may  last  only  a  few  seconds.  They  consist  in 
a  temporary  lapse  of  consciousness.  The  person  who  is 
talking  to  one  may  stop  talking,  look  very  vacant,  evi- 
dently not  hear  one,  drop  what  he  has  in  his  hands,  and 
yet  in  two  or  three  seconds  the  whole  thing  is  gone  and 
he  goes  right  on  with  what  he  was  doing.  These  attacks 
are  important  chiefly  for  their  after-effects.  A  patient 
of  mine  who  has  had  these  attacks  again  and  again 
came  to  me  one  day  very  much  troubled:  "I  had  one 
of  my  attacks  yesterday ;  I  remember  that,  and  the  next 
thing  I  found  myself  in  Chelsea.  How  I  got  there  I 
have  not  the  least  idea."  The  patient  may  be  perfectly 
unconscious  of  what  he  does  in  the  next  hour  or  so 
after  one  of  these  petit  mal  attacks.  He  may  get  into 
criminal  troubles  and  in  fact  is  very  likely  to,  because 
the  petit  mal  is  such  a  slight  thing  that  it  does  not  bring 
him  under  anybody's  care.  One  of  my  patients  who 
had  these  attacks  would  always  notice  that  people 
near  him  suddenly  began  to  grow  very  small  and  to 

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make  faces  at  him,  and  then  the  whole  thing  would 
stop  and  he  would  just  be  a  little  dazed,  but  might  not 
know  what  he  was  doing  for  some  hours  after  that. 

Epilepsy  is  for  practical  purposes  incurable.  I  do 
not  mean  that  we  cannot  find  a  cured  case ;  I  know  two 
or  three  cured  cases  out  of  hundreds  which  have  not 
recovered.  The  milder  cases  taken  early  can  sometimes 
be  cured.  Some  of  the  enthusiasts  tell  us  that  it  is  just 
like  tuberculosis,  that  we  can  cure  the  incipient  cases. 
I  do  not  think  that  this  is  quite  a  fair  comparison.  It 
is  much  rarer  to  see  a  cure  of  epilepsy  than  of  tu- 
berculosis. Epilepsy  practically  always  comes  on  in 
youth.  If  we  hear  that  a  person  has  developed  epi- 
lepsy past  forty,  we  can  be  pretty  sure  that  the  diagno- 
sis is  wrong.  They  may  develop  fits  due  to  something 
else,  such  as  syphilis  or  arteriosclerosis,  but  not  true 
epilepsy. 

The  treatment  is  a  good  deal  like  the  treatment  of 
tuberculosis,  but  one  feature  of  it  is  different.  That  is 
the  simplification  of  environment  with  the  diminution 
of  every  kind  of  strain  and  interest  and  stimulus  that 
there  is.  If  we  can  get  a  person  almost  bored  to  death 
he  may  get  better.  If  he  never  sees  anybody,  never 
does  anything,  he  may  get  better.  The  hygienic  aspect 
of  the  treatment  is  also  an  essential  part;  it  is  not 
merely  this  cure  by  boredom,  it  is  also  true  that  regu- 
lar, outdoor  life,  early  hours,  extra  amounts  of  sleep, 
make  a  difference. 

The  prevailing  view  about  epilepsy  is  that  it  is  a  sort 

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DISEASES  OF  THE  NERVOUS  SYSTEM 

of  explosion  of  gathered-up  energy,  a  brain-storm  or 
explosion,  the  result  of  stimuli  of  all  kinds,  physical 
and  psychical,  coming  into  our  senses,  and  that  the  best 
cure  is  to  reduce  all  these  stimuli.  This  we  accomplish 
in  part  by  drugs,  and  the  one  drug  which  is  practically 
always  given  and  which  is  of  use  in  diminishing  the 
number  of  convulsions  is  bromide  of  soda  or  potash. 
From  time  to  time  we  hear  that  people  are  going  to 
get  along  without  bromide,  but  we  do  not  often  find 
that  it  is  true.  Any  one  bromide  does  as  well  as  an- 
other; there  are  always  new  ones  which  are  of  interest, 
but  do  not  make  any  real  difference.  It  is  a  drug  which 
makes  us  stupid  if  we  take  enough  of  it,  makes  us 
less  keen  to  feel  the  interests  and  stimuli  of  life.  It 
acts  in  the  same  way  as  the  simplification  of  environ- 
ment that  I  have  described.  Unfortunately  it  is  bad 
for  the  patient  in  other  ways;  it  makes  him  depressed, 
torments  him  with  skin  eruptions,  and  often  upsets 
his  digestion.  Still,  in  moderation  and  combined  with 
other  kinds  of  treatment,  it  is  essential. 

One  of  the  greatest  problems  of  the  epileptic  is  his 
work.  There  are  few  employers  who  will  take  the 
responsibility  of  employing  a  man  who  has  fits.  It 
may  be  that  he  does  not  have  one  more  than  once  a 
month,  but  people  do  not  like  it  and  we  can't  blame 
them.  It  is  a  terrible  thing  to  see.  Moreover,  it  may 
occur  at  a  critical  point  in  the  management  of  a  ma- 
chine such  as  a  locomotive.  I  do  not  know  any  satis- 
factory solution  for  the  problem  of  the  epileptic  on  the 

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industrial  side.  The  places  where  it  has  been  most 
nearly  solved  have  been  colonies  like  Bielefeld,  in  Ger- 
many, where  epileptics,  with  other  people  who  could 
not  take  part  in  the  ordinary  activities  of  life,  were  set 
aside  and  kept  busy  on  simple  tasks. 

Diet  makes  a  difference  —  the  diminution  of  meat 
and  the  diminution  of  salt  especially.  We  can  cut 
down  the  number  of  fits  at  once  by  diminishing  salt, 
but  we  generally  get  the  epileptic  into  such  a  state  of 
mind  that  he  would  much  rather  have  the  fits  than  go 
on.  This  does  not  mean  merely  not  taking  salt  at  table, 
but  not  having  salt  cooked  into  food ;  if  all  salt  is  left 
out  of  food  in  this  way  it  is  a  very  great  deprivation. 
We  cannot  do  it  for  a  long  time;  patients  cannot  stand 
it.  Riots  result. 

Epilepsy  complicates  all  sorts  of  other  problems. 
For  instance,  many  of  the  insane  and  many  of  the  fee- 
ble-minded are  also  epileptic. 

Questions  and  Answers 

Q.  Will  you  tell  us  the  difference  between  the  fits  caused 
by  arteriosclerosis  and  by  epilepsy? 

A.  There  is  n't  any  difference;  but  in  one  case  the  history 
and  physical  examination  show  arteriosclerosis,  whereas  the 
examination  of  the  epileptic  is  entirely  negative. 

Q.  With  arteriosclerosis  do  you  have  a  diet  also  and  give 
bromides? 

A.  We  are  not  so  apt  to  give  bromide,  but  we  do  limit  the 
diet.  The  person  with  arteriosclerosis  does  not  have  his  fits 
with  any  regularity;  he  may  have  one  fit  and  then  never 
have  another. 

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Q.  Can  the  course  of  arteriosclerosis  be  controlled  by 
diet? 

A.  To  some  extent,  I  think,  yes  —  not  obviously  or 
brilliantly. 

Q.  Might  the  arteriosclerotic  have  petit  mal  and  no 
grand  mal  ? 

A.  Yes. 

Q.  Is  epilepsy  apt  to  lead  to  insanity? 

A.  Yes;  that  is,  if  it  lasts  long  enough,  it  generally  pro- 
duces a  mild  grade  of  dementia,  the  silly  and  mindless  type 
of  insanity;  but  that  is  very  slow.  I  have  followed  patients 
for  over  ten  years  without  seeing  much  of  any  change  in  the 
mind.  The  fits  tend  to  increase  in  intensity  as  time  goes  on. 

Q.  What  type  of  patient  should  be  sent  to  a  state  insti- 
tution such  as  Monson? 

A.  The  type  that  cannot  be  taken  care  of  at  home.  Mon- 
son is  not  a  pleasant  place.  But  it  is  a  great  deal  better  than 
nothing.  I  should  say  the  same  of  insanity.  The  patients 
whom  we  send  to  an  asylum  are  those  who  cannot  be  taken 
care  of  at  home.  It  is  a  tremendous  strain  on  those  at  home, 
a  strain  financial  and  mental.  I  know  a  great  many  epilep- 
tics now  being  taken  care  of  at  home  because  they  are  well- 
to-do.  It  is  chiefly  the  poor  who  have  to  go  to  an  institution. 

Q.  Is  epilepsy  inherited? 

A.  Not  as  such.  There  is  often  something  wrong  in  the 
inheritance.  The  alcoholic  father  has  an  epileptic  child,  or 
the  syphilitic  or  the  insane  father  has  an  epileptic  child. 


Migraine  is  another  disease  of  the  nervous  system 
without  known  pathological  basis.  We  do  not  know 
the  cause.  It  is  also  inherited,  and  here  often  directly 
inherited.  The  father  or  mother  has  sick  headaches 
and  the  son  or  daughter  has  sick  headaches.  Migraine 
is  periodic  sick  headache-  "sick"  in  the  English 

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sense  of  nauseated.  The  migraine  headache  differs 
from  other  headaches  in  that  it  is  periodic,  apt  to  come 
about  once  in  so  often  without  any  particular  relation 
to  any  particular  cause,  and  that  it  generally  runs  a 
stereotyped  course  of  so  many  hours  with  such  and 
such  manifestations,  every  time.  It  is  most  apt  to 
come  at  the  menstrual  period.  There  are  many  women 
who  never  can  go  through  a  menstrual  period  without 
a  sick  headache.  The  attack  is  apt  to  begin  in  the 
morning  and  last  till  the  next  morning,  but  it  may 
begin  at  any  time.  It  is  apt  to  be  on  one  side  of  the 
head,  and  that  is  where  the  term  came  from  -  "  hemi- 
crane."  The  pain  is  apt  to  shift  to  the  other  side  before 
the  trouble  is  over,  and  has  no  relation  to  any  struc- 
tural or  anatomical  basis,  so  far  as  we  know.  Sooner 
or  later  the  patient  becomes  nauseated,  is  apt  to  vomit, 
and  with  that  get  well,  generally  after  a  long  sleep. 

About  the  only  good  thing  we  can  say  about  this  dis- 
ease is  that  in  women  it  is  apt  to  stop  with  the  men- 
opause, or  at  any  rate  get  much  less  severe.  I  have 
never  seen  a  case  cured.  There  is  nothing  that  a  doctor 
hates  more  than  to  try  to  cure  this  type  of  headache. 
Hygiene  can  diminish  the  number  of  attacks.  People 
who  can  afford  to  devote  themselves  in  part  to  their 
health  can  have  much  less  frequent  headaches.  People 
away  on  vacation  often  do  not  have  them,  because 
vacation  means  better  hygiene.  We  can  crush  the  pain 
to  some  extent  by  heat,  and  by  drugs,  such  as  aceta- 
nilid,  phenacetin,  and  the  other  coal-tar  antipyretics, 

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DISEASES  OF  THE  NERVOUS  SYSTEM 

or  morphia.  With  some  people  nothing  affects  the  pain 
at  all.  I  see  no  reason  for  not  giving  drugs  when  they 
do  relieve.  Some  people  are  relieved  by  aspirin,  more 
are  not.  Acetanilid,  the  most  important  constituent  of 
most  headache  powders,  is  a  dangerous  drug  and  never 
should  be  given  or  taken  without  a  physician's  direc- 
tions. There  have  been  a  number  of  deaths  from  ace- 
tanilid,  but  if  taken  under  a  physician's  directions  it  is 
a  marvellous  drug  for  pain.  In  headaches  which  do 
not  come  more  than  once  a  month  and  in  persons  of 
strong  character,  we  sometimes  venture  to  give  mor- 
phine without  any  great  fear  of  creating  a  habit. 

Migraine  is  enormously  more  common  in  women 
than  in  men,  no  one  knows  why. 

Questions  and  Answers 

Q.  Does  migraine  begin  in  small  children? 

A.  I  have  never  known  it  to  do  so.  I  have  never  known  it 
before  the  tenth  year. 

Q.  Have  you  ever  known  a  case  treated  with  ideal  hy- 
giene to  see  if  it  would  disappear? 

A.  Yes;  I  have  known  a  good  many,  but  never  known  a 
single  case  to  disappear  even  with  ideal  hygiene. 

Q.  Is  thyroid  extract  sometimes  given  for  this? 

A.  Yes.  But  I  have  never  seen  any  brilliant  results. 


CHAPTER  XII 

DIABETES  —  DISEASES    OF    THE    BLOOD  —  DISEASES 
OF   THE   BONES   AND  JOINTS 

Diabetes 

So  far  I  think  every  disease  that  I  have  spoken  of  has 
hitched  itself  to  some  organ.  We  have  described  dis- 
eases of  the  heart,  of  the  lungs,  liver,  and  so  on.  But 
diabetes  is  a  disease  which  is  of  no  organ  whatever. 
At  the  post-mortem  examination  there  is  often  nothing 
to  show  for  it.  It  is  a  chemical  affair  and  not  a  physical 
affair,  and  presents  the  best  common  example  of  a 
purely  chemical  disease.  We  do  not  know  its  cause. 
We  have  no  reason  to  relate  it  to  one  bodily  organ 
rather  than  another.  The  essential  trouble  in  diabetes 
is  that  the  body  loses  its  power  to  transform  the  car- 
bohydrates of  food  into  heat  and  energy;  it  loses  the 
power  to  burn  sugar.  The  body  normally  burns  its 
food  and  so  gets  heat  out  of  it,  or  transforms  it  into 
useful  tissues.  In  this  disease  that  power  is  lost  and 
the  carbohydrate  portions  of  our  food  —  that  is,  the 
sugars  and  starches  —  pass  out  in  the  urine  as  sugar. 
They  pass  out  because  they  cannot  be  used,  and  that 
for  no  reason  that  we  know.  Diabetes  means  "wast- 
ing," and  mellitus  means  sugar,  honey.  Saccharine 
urine  is  merely  one  way  that  the  disease  manifests  it- 

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DIABETES 

self,  the  essential  thing  being  that  the  body  cannot 
take  care  of  one  of  the  three  great  portions  of  its  food. 
The  diagnosis  is  simple;  very  often  patients  make  it 
for  themselves.  The  symptoms  are  thirst,  tremendous 
hunger,  and  emaciation.  It  is  one  of  the  two  diseases 
in  which  adults  lose  flesh  despite  a  good  appetite  and 
good  digestion.  (Toxic  goitre  is  the  other.)  In  all  dis- 
eases, except  thyrotoxicosis  and  diabetes,  in  which 
adults  lose  flesh,  it  is  because  they  do  not  eat  ordo  not 
retain  or  do  not  digest. 

Diabetes  is  one  of  the  frequent  causes  of  death.  It 
figures  high  in  the  percentages  of  mortality  reports, 
and  so  far  as  we  can  tell  it  is  increasing.  There  are 
some  reasons  to  doubt  that,  because  American  mor- 
tality statistics  are  such  unreliable  things.  But  if  one 
accepts  the  face  value  of  reports,  the  number  of  deaths 
from  diabetes  is  increasing.  It  is  from  two  to  three 
times  as  common  among  the  Jewish  people  as  among 
any  other  race  in  this  country. 

Q.  Has  it  anything  to  do  with  what  they  eat? 
'  A.  No;  it  is  not  due  to  any  peculiarity  of  their  diet.  It 
has  often  been  said  to  be  associated  with  the  Jewish  tem- 
perament. The  Jewish  temperament'is  a  high-strung,  keen, 
intellectuaHemperament,  with  great  openness  to  worry,  and 
it  is  a  fact  that  many  healthy  people  can  temporarily  bring 
sugar  into  the  urine  by  fear  and  worry.  Students  at  exami- 
nation time,  and  people  who  have  been  thcough  great  grief, 
often  have  sugar  in  the  urine  temporarily.  One  guesses, 
therefore,  that  a  race  which  tends  to  emotional  strain,  worry, 
and  fear  would  be  more  easily  attacked  by  this  disease.  We 

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cannot  say  that  the  disease  is  due  to  fear  and  worry,  but 
merely  that  it  seems  to  have  some  connection  with  those 
emotions. 

Diabetics  can  be  divided  into  two  groups,  the  thin 
young  ones  and  the  fat  old  ones,  and  this,  although  it 
sounds  like  a  rather  rough-and-ready  calculation,  has 
practical  importance.  For  the  thin  young  ones  gen- 
erally die  soon,  the  fat  old  ones  often  live  for  years  and 
then  do  not  die  of  diabetes  at  all.  In  some  of  the  fat 
old  ones  it  is  hardly  more  than  a  serious  inconvenience ; 
in  the  thin  young  ones  it  is  a  tremendously  fatal  dis- 
ease. The  younger  the  worse;  in  children  any  length 
of  life  is  almost  unknown. 

The  diagnosis  is  very  easily  made  by  a  test  of  the 
urine,  which  one  can  make  in  two  minutes  and  which 
any  one  can  be  taught  in  one  minute.  We  teach  pa- 
tients now  at  the  Massachusetts  General  Hospital  to 
make  their  own  tests  of  urine  as  they  perfectly  well  can. 

As  soon  as  any  marked  worry  comes  to  the  patient's 
life,  up  goes  the  sugar,  when  it  has  been  scanty  or  ab- 
sent before.  The  management  of  this  disease  is  wholly 
a  matter  of  diet  and  hygiene,  and  we  come  near  to  be- 
ing able  to  manage  it  successfully.  Medicines  have 
absolutely  no  effect  on  it,  and  if  one  hears  of  any  pa- 
tient who  is  taking  medicine  for  diabetes  one  can  be 
tolerably  sure  that  he  is  under  the  care  of  a  quack. 
Medicines  have  no  more  effect  on  diabetes  than  on 
cancer. 

The  treatment  may  be  divided  into  two  periods  - 

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DIABETES 

that  used  up  to  two  years  ago,  and  that  used  in  the 
period  since.  I  shall  speak  most  of  the  present  period. 
In  the  period  up  to  two  years  ago,  what  we  did  chiefly 
was  to  cut  out  from  the  patient's  food  all  sugars  and 
starches,  all  carbohydrates,  and  replace  them  by  an 
excessive  amount  of  proteid  and  fat.  That  worked 
very  well  for  mild  cases,  and  for  the  fat  old  people.  It 
did  not  work  at  all  well  for  the  young  thin  ones,  and 
only  tolerably  well  for  the  middle-aged  and  medium- 
sized.  Two  years  ago  a  new  system  of  treatment  began 
to  be  used,  Dr.  Allen's.1  The  Allen  treatment  of  dia- 
betes is  the  one  that  many  physicians  are  using  in  this 
country,  either  because  they  are  convinced  of  its  value 
or  because  they  are  very  much  in  hope  to  find  it  valu- 
able. We  are  treating  all  our  cases  at  the  Massachu- 
setts General  Hospital  by  that  method.  Dr.  Allen  is 
now  at  the  Rockefeller  Institute,  where  he  has  a  most 
extraordinary  clinic.  He  will  see  only  hopeless  cases. 
Until  very  recently  he  had  not  lost  a  case;  of  all  the 
hopeless  cases  he  had  treated,  not  one  had  died.  He 
is  not  saying  that  they  are  cured  or  near  it,  but  merely 
that  no  one  has  died,  though  at  the  time  when  they 
came  to  him  they  had  apparently  only  a  few  weeks  or 
months  to  live. 

The  essential  thing  is  starvation  at  the  start.  We 
starve  every  patient  for  a  short  period  to  get  the  sugar 
out  of  the  urine.  We  never  dared  to  do  that  until  Dr. 
Allen  showed  that  it  could  almost  always  be  done 

1  See  E.  P.  Joslin,  The  Treatment  of  Diabetes.   New  York,  1916. 

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safely.  We  starve  him  one  day,  two  days,  three  days 
on  the  average,  but  as  many  days  —  up  to  ten  days  — 
as  is  necessary  to  take  the  sugar  out  of  the  urine. 
Starving  does  not  mean  the  deprivation  of  water,  but 
the  withholding  of  all  food,  and  it  is  extraordinary  how 
well  the  patients  bear  it.  So  long  as  they  are  in  bed 
they  will  get  along,  sometimes  with  no  loss  in  weight, 
sometimes  actually  with  a  gain  in  weight.  This  is  al- 
most impossible  to  believe,  but  it  is  because  they  are 
holding  water  in  the  body.  The  water  they  take  stays 
in  the  body  for  a  time  and  keeps  their  weight  up,  al- 
though they  take  no  food.  Of  course  that  is  only  tem- 
porary. In  a  little  while  the  water  is  passed  out  and 
the  weight  goes  down. 

After  a  period  of  starvation  we  begin  experimentally 
and  build  up  the  diet  to  see  what  can  be  taken  without 
the  patient's  passing  sugar  in  the  urine.  There  is  for 
each  person  an  individual  limit;  we  give  him  a  certain 
amount  of  food  and  raise  it  each  day ;  as  soon  as  sugar 
appears,  stop  and  go  down  a  little.  In  that  way  we 
work  out  what  his  permanent  diet  is;  that  is,  what  is 
the  largest  amount  of  food  he  can  take  without  pro- 
ducing sugar  in  the  urine.  When  this  is  found,  a  person 
must  usually  stick  to  it  indefinitely. 

The  great  obstacle  to  curing  people  is  that  they 
will  not  stick  to  their  diet.  They  will  break  through; 
would  rather  die  than  keep  to  what  they  have  been 
told  they  can  and  must  keep  to.  Although  there  are 
difficulties  with  the  Allen  diet,  and  the  patient  still 

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wants  a  great  many  foods  which  he  cannot  have,  it  is 
not  so  bad  as  the  old  diet.  We  used  to  force  in  enor- 
mous amounts  of  butter  and  cream,  but  butter,  when 
one  can't  have  bread,  is  not  inviting.  One  of  the  im- 
portant things  the  social  worker  can  do  is  to  warn  all 
patients  against  diabetic  breads.  They  are  one  of  the 
worst  of  frauds;  they  always  contain  starch,  they  are 
expensive,  and  they  waste  the  patient's  money.  We 
ask  a  patient,  "Do  you  eat  any  bread?"  and  they  al- 
ways say,  "No,  no  bread."  "But,"  we  say,  "you  eat 
gluten  bread,  don't  you?"  "Oh,  yes,  I  take  gluten 
bread."  Now  gluten  bread  is  just  as  bad  as  any  other 
bread,  and  it  is  expensive  and  wasteful;  if  patients  are 
going  to  eat  bread  they  had  better  eat  real  bread. 

Q.  Is  there  any  difference  between  crackers  and  bread? 
A.  No ;  most  people  would  rather  have  bread ;  but  there  is 
little  or  no  difference  in  relation  to  the  urine. 

The  diet  that  a  diabetic  patient  must  take  is  a  little 
more  expensive  than  the  average  diet,  but  not  very 
much  so;  that  is  a  great  boon.  Previous  to  Allen's  dis- 
coveries diabetic  diet  was  a  great  deal  more  expen- 
sive, the  amount  of  cream,  etc.,  brought  it  up  to  high 
figures. 

In  relation  to  social  work  the  important  points  are 
that  a  person  once  diabetic  is  always  diabetic  in  the 
vast  majority  of  cases.  They  are  to  that  extent  limited 
in  what  they  can  eat,  and  must  keep  up  the  diet  for 
life.  This  needs  self-control,  but  it  saves  life.  One  of 

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the  most  energetic,  healthy  men  that  I  know  has  now 
been  on  this  diet  for  two  and  a  half  years,  never 
worked  harder,  never  looked  better,  holds  his  weight, 
and  everything  is  going  splendidly.  We  can't  say  more 
than  that  as  to  the  future  because  Allen's  treatment 
has  been  in  use  only  three  years.  Perhaps  it  will  break 
down  with  time. 

Anything  that  makes  people  sad,  nervous,  worried, 
or  fearful  is  at  once  bad  for  the  health  and  shows  itself 
directly  in  the  urine.  I  have  no  doubt  that  the  same  is 
true  of  many  other  diseases  where  we  cannot  prove  it 
by  chemistry,  but  diabetes  is  a  disease  where  we  can 
easily  prove  the  bad  effects  on  the  body  of  depress- 
ing emotions  of  any  kind.  Any  intercurrent  infec- 
tion, grippe  attacks,  anything  that  a  diabetes  patient 
"catches,"  makes  him  worse. 

I  believe  that  before  long  a  great  deal  of  what  doc- 
tors now  do  in  the  treatment  of  this  disease  will  be 
handed  over  to  social  workers  and  to  nurses,  because 
the  doctor  can  perfectly  well  tell  somebody  else  how  to 
do  most  of  it.  It  is  so  simple.  Then  the  doctor  would 
be  free  to  do  what  he  has  trained  himself  to  do,  things 
that  require  more  technical  skill  than  this  does.  I 
think  before  long  social  workers  will  know  this  disease 
especially  and  in  detail.  A  doctor  of  my  acquaintance 
recently  told  me  that  one  of  his  secretaries  had  previ- 
ously been  secretary  to  a  specialist  in  diabetes:  "and 
now,"  he  said,  "she  knows  more  about  diabetes  than  I 
do,  although  she  has  never  had  any  medical  training  at 

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DISEASES  OF  THE  BLOOD 

all."  And  he  was  perfectly  willing  to  leave  the  treat- 
ment of  a  diabetic  to  her.  The  treatment,  not  the 
diagnosis  of  diabetes,  can  be  split  off  from  the  rest  of 
medical  knowledge  and  worked  out  through  subordi- 
nates in  this  way.  Thus  the  disease  can  be  treated 
much  more  cheaply  —  an  important  point  in  the  eco- 
nomics of  public  health. 

Q.  If  the  patient  were  not  eating  carbohydrates  would 
worry  increase  the  sugar? 

A.  Yes;  that  we  have  proved;  a  person  whose  urine  is 
sugar-free  on  a  perfectly  satisfactory  diet  can  get  sugar  into 
the  urine  by  worrying. 

Q.  Where  does  the  sugar  come  from? 

A.  Any  of  the  tissues  of  the  body  can  make  sugar;  it 
comes  from  carbohydrates ;  it  also  comes  from  proteids  and 
fats. 

Diseases  of  the  blood 

Anemia  is  the  only  common  disease  which  we  call  a 
disease  of  the  blood;  strictly  there  are  no  diseases  of 
the  blood ;  there  are  various  diseases  that  show  them- 
selves in  the  blood  and  elsewhere,  too.  Anemia  means 
a  lack  of  red  corpuscles.  Our  blood  is  a  fluid  which 
floats  upon  its  stream  two  or  three  kinds  of  cells,  the 
most  numerous  of  ^which  are  what  we  call  the  red  cor- 
puscles. It  is  these  that  give  us  color,  when  we  have 
color;  the  color  of  our  cheeks  and  lips  is  due  to  the 
redness  of  the  red  corpuscles.  These  cells  carry  oxy- 
gen from  the  lungs  to  the  tissues  and  carbon  dioxide 
from  the  tissues  to  the  lungs  and  make  that  extraordi- 
nary exchange  previously  described.  Blood  is  the  most 

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complicated  substance  known  in  the  whole  universe; 
it  has  literally  hundreds  of  other  functions  besides 
this. 

When  the  red  cells  are  deficient  in  number  or  in  size, 
they  do  not  contain  as  much  of  the  essential  substance, 
hemoglobin,  the  colored  matter  of  the  blood  —  the 
essential  thing  from  the  point  of  view  that  we  are  now 
considering  the  blood.  The  corpuscles  may  be  numer- 
ous enough,  but  each  one  of  them  individually  poor  in 
hemoglobin. 

Anemia  is  a  rare  disease.  "So-and-So  is  anemic"  is 
a  phrase  we  have  constantly  upon  our  tongues,  but 
generally  the  diagnosis  is  made  merely  upon  the  fact 
that  a  person  is  pale.  Many  of  the  palest  people  are 
never  anemic,  and  many  red-cheeked  people  are  ane- 
mic. True  anemia,  judged  by  blood  examination,  is  a 
rare  disease.  Any  social  worker  who  has  spent  much 
time  in  hospitals  must  have  seen  the  common  hemo- 
globin test  which  we  make  so  many  times  each  day 
and  which  gives  us  the  bulk  of  the  knowledge  we  need 
for  the  diagnosis  of  anemia.  We  pierce  the  skin  at  the 
least  sensitive  point,  the  ear,  suck  a  drop  of  blood  into 
a  bit  of  standard  blotting-paper,  and  compare  the 
color  of  that  drop  with  a  series  of  standard  scale  red- 
tones,  from  one  hundred,  which  we  call  the  normal  for 
adults,  down  to  the  lowest  that  we  ever  see,  which  we 
call  ten.  It  is  a  very  simple  color- matching  process, 
much  simpler  than  taking  a  temperature,  and  will  not 
long  be  thought  to  be  the  prerogative  of  people  who 

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DISEASES  OF  THE  BLOOD 

have  studied  medicine  for  four  years.  In  Germany 
and  other  places,  where  they  do  not  care  so  much 
about  pain,  doctors  puncture  the  finger  instead  of  the 
ear,  but  the  finger  is  the  worst  place  to  puncture  be- 
cause it  is  the  most  sensitive.  We  can  get  blood  much 
more  easily  from  the  lobe  of  the  ear. 

Anemia  results  in  the  first  place  from  hemorrhage; 
whoever  is  constantly  losing  blood,  or  losing  it  in  large 
quantities,  gets  anemic  before  long.  The  body  has  ex- 
traordinary power  to  make  up  loss,  and  even  a  quart 
may  be  made  up  within  a  few  weeks.  Hemorrhage 
from  the  stomach,  for  instance,  from  a  gastric  ulcer, 
hemorrhage  from  the  bowel,  from  hemorrhoids  (if  long 
continued),  from  wounds  or  operations,  from  the 
uterus,  as  from  fibroid  tumors,  are  among  the  com- 
monest causes  of  this  type  of  anemia.  If  the  cause  can 
be  removed,  if  the  hemorrhage  can  be  stopped,  this 
type  of  anemia  will  almost  always  get  well.  The  body 
will  build  up  its  blood  again  provided  the  drain  is  not 
going  on  perpetually. 

In  contrast  with  this  is  the  anemia  which  is  second- 
ary to  cancer.  Because  we  almost  never  can  remove 
the  cause  the  anemia  itself  is  almost  never  cured.  Can- 
cer of  the  stomach,  of  the  uterus,  of  the  breast,  are 
accompanied  before  long  by  a  severe  anemia.  Chronic 
kidney  trouble,  Bright's  disease,  syphilis,  rickets,  often 
produce  anemia;  also  lead  poisoning,  the  last  an  ex- 
ample of  an  anemia  which  we  ought  to  be  able  to  cure 
because  we  ought  to  be  able  to  remove  its  cause. 

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All  the  types  spoken  of  thus  far  are  what  we  call 
"  secondary  anemia."  That  means  that  they  are  due 
to  a  cause  which  we  know.  In  contrast  with  that  there 
are  two  types  of  "primary  anemia,"  -  that  is,  anemia 
of  unknown  cause;  "primary"  never  means  any  more 
than  that  we  do  not  know  the  cause.  The  commonest 
of  these  is  called  pernicious  anemia,  and  is  a  disease 
which  is  thus  far,  except  for  a  short  time,  incurable. 
In  post-mortem  no  cause  is  found  in  these  cases.  The 
person  loses  color,  the  number  of  corpuscles  in  the 
blood  diminishes  all  the  time,  although  there  is  no 
hemorrhage,  the  patient  gets  to  be  of  a  sickly  pallor, 
and  finally  dies  without  suffering,  because  he  has  n't 
blood  enough  to  keep  him  going.  This  is  a  disease  of 
elderly  people,  usually  past  forty-five.  All  sorts  of 
causes  have  been  assigned,  but  we  have  not  any  idea 
of  its  real  cause.  The  two  things  which  do  the  most 
good  temporarily  are  the  transfusion  of  blood  from 
another  person,  and  taking  out  the  spleen  by  opera- 
tion or  by  X-ray. 

The  transfusion  of  blood  from  another  person  has 
perfectly  miraculous  effects  for  a  short  time.  Recently, 
in  the  Massachusetts  General  Hospital,  a  very  ad- 
vanced case  of  pernicious  anemia  had  just  been  ad- 
mitted when  I  made  my  visit.  His  color  was  like  that 
of  pale  yellow  paper,  not  a  trace  of  normal  human 
color  anywhere  in  his  face.  Next  day,  to  my  surprise, 
he  had  so  bright  a  color  in  his  cheek  that  I  could  hardly 
believe  it  was  the  same  man.  The  house  officer  said, 

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DISEASES  OF  THE   BLOOD 

"Oh,  yes,  we  transfused  him  yesterday."  That  was 
some  weeks  ago  and  to-day  he  is  as  rosy  a  specimen  as 
you  would  like  to  see.  We  know  he  won't  stay  thus. 
These  improvements  are,  so  far  as  we  know,  never 
permanent,  but  for  the  time  being  he  is  vastly  better. 
Ordinarily  we  should  go  right  ahead  and  take  out  his 
spleen,  but  in  this  case  there  is  one  first-class  reason 
why  we  do  not  —  namely,  we  took  it  out  last  year. 

We  take  out  the  spleen  because  the  spleen  is  sup- 
posed to  act  as  a  destroyer  of  red  corpuscles.  We  have 
no  idea  what  the  spleen  is  good  for,  but  we  have  some 
notion  of  the  harm  it  does,  especially  in  pernicious 
anemia.  It  certainly  destroys  red  corpuscles,  even  in 
healthy  people.  But  it  has  been  supposed  until  re- 
cently that  it  only  destroyed  those  that  were  pretty 
nearly  dead  anyway.  After  splenectomy  these  pa- 
tients have  done  better  than  after  transfusion  or  after 
any  medication  that  we  have  known.  We  have  some 
that  have  been  alive  for  two  years  and  are  still  well, 
and  it  is  possible  but  not  at  all  probable  that  we  may 
cure  some  of  them. 

In  transfusion  we  give  ordinarily  about  half  a  pint  of 
blood.  Of  course,  that  is  not  enough  to  make  up  what 
is  missing.  What  it  does  is  to  stimulate  the  bone  mar- 
row (where  the  new  red  corpuscles  are  made)  so  that 
it  takes  up  the  job  that  it  had  abandoned. 


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Questions  and  Answers 

Q.  Does  it  make  any  difference  in  the  selection  of  the 
person  for  the  transfusion?  Must  he  be  related? 

A.  He  must  be  related  biologically,  but  need  not  be  of  the 
same  family.  We  first  test  the  blood  of  the  patient  with  the 
blood  of  the  donor ;  any  candidate  has  to  be  first  tested  to  see 
that  his  blood  does  not  break  up  or  interfere  with  the  blood 
of  the  patient.  Sometimes  relations  won't  do  at  all,  and 
a  mere  stranger  is  all  right.  In  one  recent  case  a  patient's 
son  who  was  ready  and  willing  to  give  blood  was  found  to  be 
entirely  useless,  but  we  have  donors  on  tap  at  ten  dollars 
each.  We  can  always  get  them  from  Harvard.  After  giving 
blood  the  donor  may  feel  a  little  "seedy"  for  two  or  three 
days ;  after  that  he  is  as  good  as  new.  I  think  this  is  one  of 
the  most  picturesque  aspects  of  medicine.  We  so  often  hear 
from  friends  and  relatives  of  the  sick,  "Oh,  if  I  could  only 
do  something!"  This  is  one  case  where  a  friend  can  do  a 
great  deal ;  indeed  he  may  save  life  though  not  in  pernicious 
anemia.  We  transfuse  in  other  diseases  also  where  the  at- 
tempt means  simply  the  difference  between  life  and  death. 
The  technique  is  to  go  straight  from  vein  to  vein;  open  a 
vein  in  the  donor,  transfer  the  blood  to  a  glass  receptacle 
coated  with  paraffin,  open  the  vein  of  the  patient,  and  put 
the  new  blood  in. 

When  people  have  an  uncontrollable  oozing  of  blood  from 
the  gums  or  the  stomach  or  the  navel,  or  any  other  place, 
they  have  this  tendency  because  their  blood  lacks  something 
which  ought  to  promote  clotting.  Giving  them  somebody 
else's  blood  often  gives  them  the  clotting  substance  which 
they  need.  In  children  transfusion  is  usually  done  for  that 
purpose. 

Q.  Do  you  have  to  be  sure  that  there  is  no  taint  of 
syphilis? 

A.  We  certainly  do.  We  always  make  a  Wassermann 

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DISEASES  OF  THE  BLOOD 

test;  of  course  we  could  not  do  a  greater  injury  than  to  use 
tainted  blood.  - 

Q.  Can  donors  go  through  this  operation  several  times? 

A.  Yes;  perfectly  well.  We  were  sure  in  advance  that  this 
would  be  so  from  our  long  experience  with  horses  and  other 
animals.  The  method  of  making  diphtheritic  anti-toxin  is  to 
take  the  blood  of  a  horse  which  has  been  immunized  against 
diphtheria.  Such  a  horse  may  be  bled  and  bled  at  proper 
intervals  until  gallons  of  blood  are  taken  out  of  him,  yet  he 
thrives  on  it.  It  does  not  even  diminish  his  appetite,  and 
human  beings  seem  to  do  just  as  well. 

The  other  primary  anemia,  the  other  anemia  for 
which  we  know  no  cause,  is  one  which  is  now  getting 
rare.  When  I  was  a  medical  student  we  used  to  see 
many  cases  of  it ;  that  is,  the  picturesque  disease  called 
chlorosis,  which  was  supposed  to  mean  "green,"  the 
" green  sickness."  I  remember  being  greatly  excited 
with  the  hope  of  seeing  one  of  these  green  patients ;  but 
they  are  not  green,  simply  pale.  It  means  an  anemia 
of  young  girls,  between  fifteen  and  twenty-four,  ordi- 
narily coming  on  a  few  years  after  the  establishment  of 
menstruation,  without  any  known  cause  whatsoever. 
It  is  as  common  in  the  rich  or  well-to-do  as  in  the  poor. 
It  can  be  easily  cured  by  iron.  This  is  another  of  the 
small  list  of  diseases  referred  to  above  which  we  can 
cure  with  a  drug,  and  we  can  do  it  every  time.  We  do 
not  even  have  to  rectify  the  patient's  bad  hygiene  so 
long  as  she  will  eat  a  certain  amount  of  iron.  Why  it 
occurs  only  in  women,  and  why  only  in  women  at  this 
particular  age,  why  it  is  now  apparently  disappearing 

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from  America,  are  questions  that  have  never  been 
answered.  I  have  not  seen  a  case  now  for  several  years ; 
I  used  to  see  many  every  year. 

So  far  we  have  been  describing  troubles  with  the  red 
cells  in  the  blood.  Leucemia  is  a  rare  disease,  invariably 
fatal,  characterized  by  an  enormous  accumulation  of 
the  other  chief  solid  constituent  of  the  blood  stream, 
the  white  cell  or  leucocyte.  Anemia  means  too  few  red 
cells:  leucemia  (literally  "white  blood")  means  too 
many  white  cells.  The  blood  is  never  white,  but  some 
imaginative  gentleman  thought  it  might  be,  because  of 
the  color  of  the  clots  post  mortem.  We  do  not  know  the 
cause  and  have  almost  no  control  for  the  course  of  the 
disease.  It  can  be  diagnosed  in  a  few  seconds  from  a 
blood  specimen,  and  is  perfectly  easy  to  diagnose  if  one 
thinks  of  examining  the  blood;  entirely  impossible  if 
one  does  not. 

The  present  treatment  is  wholly  by  X-ray  or  radium, 
and  this  does  a  great  deal  of  good  in  prolonging  life, 
although  it  never  yet  has  cured  any  one.  I  had  a  pa- 
tient once  who  came  here  from  Cuba,  a  coffee- planter; 
he  took  X-ray  treatment  at  the  Massachusetts  General 
Hospital  and  was  so  impressed  with  it  that  he  bought 
an  X-ray  machine,  carried  it  back  to  Cuba  and  gave 
himself  the  treatment.  He  lived  and  worked  there  for 
a  couple  of  years  and  then  came  back  and  died.  That 
is  about  the  best  we  can  expect. 

Purpura  is  a  symptom  miscalled  a  disease,  but  so 
common  a  symptom  that  it  ought  to  be  defined,  at 

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least,  before  I  leave  this  subject.  It  means  spontane- 
ous bleeding  under  the  skin,  red  spots  of  blood  appear- 
ing under  the  skin  from  unknown  causes.  It  is  a  symp- 
tom of  many  diseases ;  for  example,  of  many  infectious 
diseases.  We  see,  from  time  to  time  in  the  newspapers, 
that  there  is  an  epidemic  of  " spotted  fever."  "Spotted 
fever"  is  one  of  the  many  diseases  that  has  purpura  as 
a  symptom.  It  occurs  sometimes  as  a  result  of  drugs, 
such  as  iodide  of  potash  or  bromides  or  salicylate  of 
sodium.  Purpura  also  comes  in  people  who  are  badly 
run  down  from  any  cause;  as,  for  example,  in  tubercu- 
lous or  cancerous  or  diabetic  or  nephritic  patients. 

Purpura  is  distinct  from  another  disease  that  belongs 
in  this  group,  hemophilia,  which  is  the  technical  term 
for  "a* bleeder,"  a  person  who  tends  to  bleed  on  very 
slight  provocation.  Purpura  is  spontaneous;  hemo- 
philia is  bleeding  from  some  known  cause  as  from  hav- 
ing a  tooth  pulled.  Patients  may  bleed  to  death  from 
hemophilia.  A  slight  cut  may  give  an  almost  uncon- 
trollable hemorrhage.  Luckily  the  disease  is  very  rare. 
I  mention  it  only  because  it  is  one  of  the  most  inter- 
esting diseases  from  the  point  of  view  of  heredity.  It 
sounds  impossible,  and  yet  it  is  demonstrably  true  that 
the  disease  is  transmitted  through  the  females  to  the 
males.  Men  have  it,  women  do  not  have  it,  and  yet  it 
is  transmitted  only  through  women  —  a  most  extraor- 
dinary state  of  things.  A  man  who  is  a  bleeder  has  a 
daughter;  she  is  never  a  bleeder,  but  her  son  may  be; 
her  daughter  never  can  be ;  but  she  can  transmit  it  to 

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her  son  and  so  on.   There  are  families  where  this  has 
been  followed  through  six  or  seven  generations. 

We  are  beginning  to  have  some  idea  of  how  to  help 
both  purpura  and  hemophilia  through  transfusion.  In 
both  diseases  the  blood  lacks  something  that  ought  to 
make  it  clot,  and  by  supplying  that  we  can  sometimes 
save  life. 

Diseases  of  the  Lymph  Glands 

Besides  the  veins  and  the  arteries  which  carry  the 
blood  out  from  the  heart  and  back  to  the  heart,  there 
is  in  the  body  another  set  of  tubes,  the  lymph  channels. 
They  carry  lymph,  a  colorless  fluid  quite  unlike  the 
blood;  they  go  everywhere,  into  every  organ  in  every 
part  of  the  body,  and  now  and  then  they  come  to  a  sub- 
station which  is  a  lymph  gland.  Lymph  glands,  which 
are  masses  of  lymph  cells,  occur  everywhere,  but  are 
largest  in  certain  familiar  sites  in  the  body  —  in  the 
first  place,  in  the  throat,  (i)  The  tonsils,  the  adenoids, 
and  all  the  other  lumps  of  tissue  round  the  ring  of  the 
throat  are  lymph  glands.  There  are  a  great  many  more 
of  them  than  we  give  names  to.  The  throat  is  full  of 
them.  Then  (2)  there  is  a  large  group  on  the  sides  of 
the  neck  which  are  not  ordinarily  big  enough  to  feel  or 
to  see  unless  they  are  diseased.  (3)  There  is  a  group  in 
each  arm  pit,  and  (4)  another  group  in  each  groin. 
Those  are  the  chief  groups  which  we  can  feel  on  the 
outside  of  the  body.  There  are  a  great  many  more  in- 
side the  body,  but  they  do  not  concern  us  now. 

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DISEASES  OF  THE  LYMPH  GLANDS 

Enough  has  been  said  above  about  the  tonsils.  I  did 
not  say,  however,  anything  about  the  enlarged  glands 
in  the  neck,  which  are  very  often  seen  in  children. 
Glands  swell  up  in  the  neck  in  response  to  irritations 
inside  the  mouth,  and  presumably  represent  an  effort 
on  the  part  of  the  body  to  kill  disease.  The  germs  of 
disease  are  carried  in  lymph  channels  until  they  strike 
a  lymph  gtand.  The  gland  tries  to  kill  the  germ  and 
in  the  effort  the  gland  grows  larger  and  presumably 
stronger.  Then  we  see  the  swollen  gland  and  falsely 
call  it  disease-  Really  it  represents  heroic  effort.  If  a 
child  has  a  diseased  tooth  or  an  abscess  about  a  tooth, 
there  are  very  apt  to  appear  enlarged  glands  in  the 
neck.  In  children  this  is  probably  much  the  com- 
monest cause  for  the  enlarged  glands  that  we  so  often 
see.  They  do  not  represent  disease  really ;  they  repre- 
sent resistance  against  septic  disease,  and  they  should 
not  be  treated  unless  they  suppurate  —  unless  pus 
forms,  when  it  has  to  be  let  out. 

Next  to  this  type  is  the  tuberculous  gland  in  the  neck, 
also  seen  especially  in  children,  sometimes  very  hard  to 
tell  from  the  kind  mentioned  last,  but  characterized  by 
the  fact  that  they  last  a  long,  long  time,  whereas  the 
other  type  is  generally  gone  within  a  few  months. 
Tuberculous  glands  may  stay  for  years,  but  sooner  or 
later  they  almost  always  break  down  and  discharge 
slowly.  In  my  opinion  a  great  deal  of  unnecessary 
surgery  has  been  done  upon  these  glands.  In  the  vast 
majority  of  cases  if  a  surgeon  takes  them  out  there 

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A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

are  just  as  many  there  again  within  a  short  time;  the 
proper  treatment  is  that  which  Dr.  John  B.  Hawes  has 
emphasized  so  much  —  the  treatment  by  hygiene,  as 
for  lung  tuberculosis,  and  by  tuberculin.  If  an  abscess 
forms,  of  course  it  has  to  be  drained,  but  unless  there 
is  an  abscess  I  do  not  believe  in  operating  upon  them. 

Syphilis  produces  enlarged  glands  in  the  neck  which 
never  break  down  or  suppurate,  which  demand  no 
treatment,  but  which  help  the  doctor's  diagnosis. 
Malignant  disease:  cancer  and  other  types  of  malig- 
nant disease,  are  prone  to  spread  to  the  glands  of  the 
neck,  usually  secondary  to  cancer  elsewhere.  Cancer 
of  the  thyroid  or  in  the  mouth  or  in  the  lung  will  some- 
times be  known  first  because  of  an  enlarged  gland 
found  in  the  neck. 

The  chief  thing  to  remember  is  that  a  gland  as  such 
does  not  represent  anything  that  ought  to  be  treated. 
It  is  only  to  be  treated  in  case  it  suppurates,  when  it 
has  to  be  treated  like  any  other  suppuration.  When 
the  enlarged  glands  do  not  require  any  treatment  they 
do  not  cause  any  discomfort,  but  some  people  have 
them  operated  on  because  they  do  not  like  their  looks. 

Diseases  of  the  Thyroid  Gland 

Diseases  of  the  thyroid  gland  —  one  common  and  one 
rare.  The  common  one  is  goitre,  the  rare  one  myxe- 
dema.  Goitre  may  be  toxic  or  non- toxic,  that  is,  it  may 
have  with  it  symptoms  of  self-poisoning  or  none.  The 
non-toxic  goitre  is  simply  a  disfigurement,  a  lump  at 

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DISEASES  OF  THE  THYROID  GLAND 

the  root  of  the  neck  in  front.  In  some  parts  of  the 
world  it  is  fashionable  and  almost  universal.  There 
are  some  places  in  Switzerland  where  almost  every 
woman  has  a  non- toxic  goitre.  A  great  many  opera- 
tions are  done  for  cosmetic  reasons.  This  type  of  goitre 
has  no  symptoms  whatever,  and  if  a  person  is  wearing 
a  high  collar  it  does  not  disfigure.  Operation  skilfully 
done  can  make  things  look  a  good  deal  better.  It  is 
possible  to  do  the  operation  without  leaving  much  of 
any  visible  scar  and  without  any  danger  from  taking 
out  too  much  of  the  gland.  Removal  of  the  whole  gland 
is  very  serious  and  produces  the  disease  myxedema.1 

Much  more  important  to  us  is  the  toxic  goitre,  which 
receives  a  great  many  names.  It  is  called  (i)  exophthal- 
mic goitre  (ophthalmos,  the  eye;  ex,  which  means  that 
the  eyes  stand  out),  prominence  of  the  eye,  which  is  a 
symptom  of  some  cases,  not  by  any  means  all.  It  is  a 
bad  name,  because  many  cases  do  not  have  that  symp- 
tom; (2)  Graves' s  disease,  from  an  Englishman  who 
described  it;  but  of  course  no  German  will  allow  that, 
and  in  Germany  it  is  called  (3)  Basedow's  disease. 
Those  are  the  three  names  we  hear  most  often.  A 
great  many  times  it  is  called  hyperthyroidism,  which  of 
course  we  know  now,  from  our  knowledge  of  stems, 
means  too  much  thyroid.  That  is  again  a  bad  term, 
because  very  often  there  is  not  too  much  thyroid.  Thy- 
rotoxicosis  is,  I  think,  the  best  single  word  for  it.  That 
means  a  poisoning  coming  from  the  thyroid  gland. 

1  See  page  311. 
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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

It  is  a  disease  of  great  interest  in  many  ways.  One 
of  its  most  interesting  features  is  that  the  patient  with 
a  well-developed  case  presents  the  physical  evidences 
of  terror.  A  person  in  terror  does  not  necessarily  show 
it  on  the  outside,  but  if  he  does  he  will  present  the  ap- 
pearance of  the  patient  with  thyrotoxicosis.  A  person 
with  this  disease  trembles  and  sweats,  has  a  rapid  heart 
and  a  staring  eye,  so  that  as  you  meet  people  with  this 
disease  they  look  as  if  they  were  permanently  terrified. 
As  we  know  them  better,  we  see  that  it  is  just  the  phy- 
sical evidences  without  the  psychical  side  of  terror. 
More  than  that,  extraordinary  terror  sometimes  pro- 
duces the  disease.  People  have  been  known  to  come 
out  of  great  strains,  out  of  battle  for  instance,  with  the 
disease.  All  of  that  is  taken  to  mean  that  terror  has  an 
effect  upon  the  nerves  which  go  to  the  thyroid,  so  that 
when  we  are  terrified  our  thyroid  is  overworking,  and 
because  it  is  overworking  we  have  the  familiar  physical 
manifestations  of  the  invisible  psychical  state,  fear. 
When  a  person  has  been  tremendously  terrified  the 
thyroid  may  get  overworking  and  keep  overworking. 
It  is  not  quite  so  simple  as  that,  however,  because  it  is 
not  simply  overwork  —  it  is  a  perverted  work.  It  is  a 
toxic  secretion  and  not  merely  an  increased  secretion. 
Moreover,  most  cases  have  no  terror  as  their  cause, 
and  as  to  their  real  cause  we  are  entirely  in  ignorance. 

The  main  symptoms  of  goitre  are  exophthalmos,  fine 
tremor  of  the  hands,  nervousness,  and  rapid  heart. 
Another  is  loss  of  flesh  despite  a  good  appetite  and 

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DISEASES  OF  THE  THYROID  GLAND 

despite  plenty  of  food  eaten  and  digested.  There  are 
only  two  diseases  in  which  people  lose  flesh  in  spite  of 
a  good  appetite  and  plenty  of  food;  this  is  one,  and 
diabetes  is  the  other.  These  toxic  goitre  patients  burn 
up  their  food  and  their  tissues  faster  than  other  people 
and  have  to  have  more  food  to  keep  them  from  getting 
thin. 

A  superficial  but  rather  useful  way  of  making  a  guess 
at  the  disease  is  by  shaking  hands.  As  we  shake  hands 
with  people  we  can  notice  various  things  about  the 
hands  —  warm  or  cold,  or  moist  or  dry.  The  cold, 
moist  hand,  for  instance,  is  the  hand  of  a  nervous  per- 
son, and  the  hot,  dry  hand  is  the  hand  of  fever;  those 
are  common.  The  cold,  dry  hand  is  the  hand  of  the 
person  who  is  cold.  But  the  hot,  moist  hand  is  seen  in 
this  disease,  toxic  goitre,  much  more  often  than  in  any 
other  state.  The  patient  is  apt  to  have  a  little  fever 
and  a  little  extra  perspiration,  therefore  a  hot,  moist 
hand. 

The  disease  runs  a  very  chronic  course,  often  lasts 
for  thirty  or  forty  years,  and  has  an  extraordinary 
tendency  to  get  better  and  worse  and  finally  better, 
whatever  we  do,  and  entirely  without  treatment  in 
many  cases.  For  this  reason  there  is  probably  no  dis- 
ease for  which  so  many  medicines  have  been  praised 
and  so  many  treatments  tried  and  given  up.  The  rea- 
son is  that  a  person  has  got  better  and  the  doctor  has 
followed  that  most  common  of  all  fallacies,  post  hoc 
ergo  propter  hoc,  which  is  to  say  that  since  an  improve- 

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A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

ment  happened  after  a  certain  treatment,  it  happened 
because  of  that  treatment. 

I  do  not  mean  to  convey  the  impression  that  I  do 
not  think  treatment  does  any  good  in  toxic  goitre,  but 
only  that  the  disease  has  a  tremendous  tendency  to  get 
better  of  itself,  and  to  get  worse  of  itself.  I  have  fol- 
lowed one  patient  for  over  thirty  years  and  have  seen 
her  in  the  end  get  much  better  without  any  reference 
that  I  could  see  to  any  treatment  whatsoever.  The 
treatments  in  vogue  at  the  present  time  may  be  said  to 
be  three:  In  the  first  place,  the  easiest  thing  to  do,  and 
the  thing  which  will  always  help  mild  cases,  is  to  put 
the  patient  to  bed  for  two  or  three  months.  This  is  a 
pretty  stiff  treatment,  but  it  will  almost  always  make 
the  patient  better,  and  it  may  be  all  that  is  necessary. 
Indeed,  it  may  do  just  as  much  good  as  a  surgical  oper- 
ation. What  the  surgeon  generally  advises  is  to  try 
medical  treatment  first,  and  if  it  fails,  then  surgical 
treatment.  We  should  try  rest  thoroughly  first.  Now- 
adays we  also  advise  patients  to  try  X-ray.  We  are 
very  much  interested  just  at  the  present  time  in  a  large 
series  of  cases  getting  X-ray  treatment  and  nothing 
else.  They  are  most  of  them  improving,  perhaps  be- 
cause of  X-ray,  perhaps  in  spite  of  it.  The  surgeons 
are  getting  a  little  indignant  with  us,  but  we  respond 
that  the  patients  are  most  of  them  getting  better  and 
that  hence  we  do  not  see  any  present  reason  for  sur- 
gery. It  may  be  that  they  won't  continue  to  get  better, 
but  so  far  we  are  feeling  very  much  encouraged.  X-ray 

310 


DISEASES  OF  THE  THYROID  GLAND 

will  decrease  the  function  of  many  glands,  and  if  this 
disease  is  in  part  overwork  on  the  part  of  the  thyroid, 
it  is  perfectly  reasonable  to  think  that  X-ray  may  help. 

If  rest  and  X-ray  fail  we  have  as  a  last  resort  opera- 
tion, which  has  helped  a  great  many  people.  The  oper- 
ation consists  of  removing  part  of  the  gland,  or  tying 
some  of  the  blood  vessels  which  take  blood  to  the  gland, 
so  as  to  make  it  shrivel  up  in  part.  That  operation  has 
a  real  place,  I  think,  provided  people  do  not  rush  to  it 
as  the  first  thing  instead  of  the  last  thing  to  be  tried. 
If  no  treatment  is  given,  the  disease  may  get  better, 
but  may  get  steadily  worse,  and  people  may  die  of  it. 
They  usually  die  of  cardiac  failure.  The  heart  pounds 
away  and  finally  wears  itself  out. 

Myxedema  is  so  rare  a  disease  that  I  should  not  men- 
tion it  at  all  if  it  were  not  for  the  distinctive  fact  that 
it  is  one  of  the  eight  or  nine  diseases  in  the  whole  of 
medicine  that  we  can  really  cure  with  a  drug.  It  is  a 
disease  that  comes  when  the  thyroid  does  not  do  its 
work,  atrophies.  The  same  disease  in  a  child  is  called 
cretinism;  a  cretin  is  a  child  whose  thyroid  does  not 
work.  Myxedema  occurs  usually  in  women,  but  occa- 
sionally in  men  also.  The  cure  is  simply  feeding  the  in- 
dividual with  dried  thyroid  gland  from  an  animal.  It 
is  one  of  the  most  characteristic  instances  of  how  ani- 
mals help  us.  They  give  us  what  we  need  here,  and  it 
seems  to  do  just  as  well  as  a  human  thyroid  —  the 
distinction  between  a  sheep's  thyroid  and  a  human 
thyroid  does  not  make  any  difference.  A  doctor  who 


A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

recognizes  a  case  of  myxedema  can  consider  his  fortune 
made.  The  patient  who  has  been  going  down  and 
down  proceeds  to  get  entirely  well ;  she  naturally  tells 
every  one,  and  the  doctor's  reputation  sprouts.  It  is  a 
disease  that  the  doctor  prays  that  he  may  see.  Natu- 
rally, after  treating  the  vast  number  of  cases  that  we 
cannot  cure,  we  are  rather  hungry  for  a  few  that  we 
can. 

Myxedema  looks  like  obesity  plus  stupidity.  The 
placid  and  "cow-like"  expression  of  the  patients  has 
been  often  spoken  of.  They  are  troubled  with  dry  skin 
and  rapid  loss  of  hair,  gain  flesh  rapidly,  and  lose  their 
mental  and  bodily  activities,  without  any  special  organ 
being  singled  out.  They  may  become  absolutely  bald 
in  a  short  time,  but  the  hair  all  comes  back  as  soon  as 
they  are  fed  thyroid  extract.  Of  course  they  must  take 
thyroid  extract  for  life,  but  once  the  proper  dose  for 
the  individual  is  found  it  is  not  much  bother  to  take 
the  tablets. 

Diseases  of  the  Bones  and  Joints 

Tuberculosis  of  the  bones.  I  said  at  the  outset  that  I 
should  omit  tuberculosis  of  tne  lungs  because  it  is  so 
familiar;  but  bone  tuberculosis  is  not  so  much  talked 
about.  The  commonest  form  is  hip  disease.  There  are 
practically  only  two  kinds  of  hip  disease,  the  tubercu- 
lous type  and  one  other  that  comes  in  old  people.  So 
that  hip  disease  in  young  people  is  practically  always 
tuberculous.  The  only  exception  is  congenital  hip 

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DISEASES  OF  BONES  AND  JOINTS 

disease,  where  the  hip  is  out  of  its  socket  when  the 
child  is  born. 

The  first  thing  to  be  said  is  that  hip  tuberculosis 
ought  to  get  well;  it  is  an  entirely  different  prognosis 
from  tuberculosis  of  the  lungs.  Death  from  tubercu- 
losis of  the  hip  joint  usually  means  poor  work  some- 
where, provided  of  course  the  patient  has  no  tubercu- 
losis elsewhere.  The  disease  shows  itself  by  a  limp  and 
by  a  stiffening  of  the  back  and  muscles  around  the  hip. 
The  favorite  doctor's  test  for  it  is  to  throw  a  bunch  of 
keys  on  the  floor  and  ask  the  child  to  pick  them  up. 
The  child  gets  down  with  a  stiff  back  which  is  very 
characteristic.  In  an  older  person  it  would  not  be  so 
important,  but  in  young^jM[jlren  this  is  a  useful  diag- 
nostic sign.  Before  long  fever  appears  and  the  familiar 
results  of  fever,  loss  of  strength,  loss  of  weight,  loss  of 
appetite.  If  no  treatment  is  given,  or  sometimes  even 
when  it  is  given,  the  tuberculosis  which  starts  in  the 
head  of  the  hip  bone  begins  to  burrow  out  and  appear 
as  abscesses  about  the  hip.  The  pus  goes  five  or  six 
inches  before  it  reaches  the  surface.  The  abscesses 
finally  do  reach  the  surface  and  form  what  are  called 
"cold  abscesses."  These  are  abscesses  of  tuberculous 
pus  mixed  with  the  ordinary  type  of  inflammation.  It 
is  a  long-standing  disease,  lasts  for  years,  but  ought,  as 
I  have  said,  to  get  well. 

The  treatment  involves  fixing  the  joint  by  appara- 
tus, an  arrangement  whereby  the  child  can  walk  with- 
out touching  his  leg  to  the  ground,  a  complicated  splint 


A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

which  surrounds  the  leg  in  such  a  way  that  the  leg 
hangs  free  and  yet  has  something  like  a  stilt  on  the 
ground.  We  see  many  children  hopping  around  with 
these  splints  and  getting  the  outdoor  air  that  they 
need.  Besides  this  local  treatment  they  need  all  that 
the  tuberculous  lung  case  needs  of  rest,  outdoor  air, 
and  food.  A  good  deal  of  interest  just  now  is  centred 
around  the  use  of  sunlight  —  the  direct  exposure  of 
these  children  to  sunlight,  one  portion  of  the  body  after 
another  being  stripped  and  tanned  in  the  sun.  If  we 
expose  bacteria  to  sunlight  it  will  kill  most  kinds.  It  is 
not  the  heat  of  the  sun,  but  something  in  its  chemical 
action  that  kills  them.  The  present  idea  is  that  the 
sunlight  penetrates  much  .giqre  deeply  into  the  tissues 
than  we  used  to  think,  and  perhaps  kills  tubercle 
bacilli  or  encourages  sound  tissue  in  the  deeper  parts 
where  the  disease  is. 

Q.  Has  not  that  been  proved  to  be  true  with  pulmonary 
tuberculosis? 

A.  It  is  generally  believed  that  sunlight  is  of  value  to 
patients,  and  yet  the  climate  in  which  more  cases  recover 
than  any  other  is  one  of  the  most  sunless  of  climates,  Sara- 
nac. 

Q.  Do  you  have  cold  abscess  only  in  tuberculosis? 

A.  Yes.  We  may  make  a  mistake  and  think  we  have  it 
in  something  else,  but  cold  abscess  is  supposed  to  mean 
tuberculous  abscess. 

Tuberculosis  of  the  spine,  or  Pott's  disease.  Mr.  Pott 
is  responsible  for  two  diseases,  being  also  associated 
with  a  certain  common  fracture  of  the  leg,  Pott's  frac- 


DISEASES  OF   BONES  AND  JOINTS 

ture,  which  must  not  therefore  be  mixed  up  with  Pott's 
disease  of  the  spine.  The  greatest  possible  honor  for  a 
physician  is  to  have  his  name  associated  with  some 
loathsome  disease.  Pott's  disease  of  the  spine  is  tuber- 
culosis in  the  vertebrae  and  is  the  cause  of  hunchback. 
A  hunchback  is  a  person  who  has  had  an  untreated  and 
yet  arrested  case  of  tuberculosis  in  the  spine.  It  de- 
velops in  the  vertebrae  and  telescopes  them,  so  that  the 
person  is  generally  shorter  as  a  result,  and  if  it  is  not 
recognized  early  the  spine  bends  out  backward  and 
forms  what  we  call  "a  knuckle."  This  is  quite  different 
from  lateral  spinal  curvature ;  it  is  a  sudden  backward 
bend  and  quite  a  sharp  bend.  The  diagnosis  should  be 
verified  by  X-ray.  The  most  expert  won't  say  whether 
a  given  prominence  is  tuberculous  until  he  has  an 
X-ray  which  shows  very  clearly  a  focus  of  disease  in 
the  bones  of  the  spine.  If  it  is  recognized  early  there 
will  be  no  hunchback,  no  considerable  prominence,  and 
what  little  there  is  can  be  made  to  disappear  as  a  result 
of  treatment.  All  the  most  terrible  results  of  this  dis- 
ease are  due  to  its  not  being  recognized  and  treated, 
for  this,  like  hip  disease,  ought  to  be  cured. 

Q.  How  long  has  that  been  true? 

A.  It  has  been  true  now  I  should  say  for  something  like 
twenty  years,  more  true  in  Boston  than  elsewhere.  Boston 
is  the  home  of  advanced  orthopedic  work  and  people  have 
come  here  from  all  over  the  world  to  see  the  work  of  Dr. 
Bradford  and  the  older  orthopedists.  The  Bradford  Frame 
is  an  arrangement  for  keeping  a  child  with  spinal  disease  in 
right  position  for  the  best  healing  of  his  disease. 

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The  treatment  is  essentially  the  same  as  in  hip  disease. 
We  strive  to  keep  the  diseased  part  quiet  to  prevent  the 
grinding  of  the  bones  one  upon  the  other,  to  keep  the  patient 
in  the  fresh  air,  to  give  him  an  abundance  of  food,  and,  I 
guess,  of  sunlight.  What  we  are  always  afraid  of  is  that  there 
will  be  tuberculosis  of  the  lungs  which  has  not  been  recog- 
nized. If  it  is  only  in  the  spine  we  have  good  hopes  of  the 
future.  When  the  disease  recovers,  the  person  has  a  stiff 
back  in  that  part  of  the  spinal  column  which  has  been  af- 
fected, and  sometimes  is  admired  for  his  military  carriage. 

Tuberculosis  occurs  also  in  the  ribs  and  less  often  in 
the  bones  of  the  arm,  also  in  the  bones  of  the  leg,  but 
much  less  often  than  in  the  spine  and  hip.  Wherever  it 
is  it  produces  a  cold  abscess,  an  abscess  without  fever, 
very  slow  in  its  course,  an  abscess  which  when  probed 
is  found  to  lead  to  a  diseased  bone.  Any  doubtful  case 
is  always  examined  by  X-ray  to  see  whether  the  bone 
is  affected.  Tuberculosis  in  the  ribs  or  the  wrist  is 
treated  in  exactly  the  same  way  that  I  have  spoken  of 
in  relation  to  the  hip  and  spine,  except  that  the  prob- 
lem of  procuring  rest  is  not  so  serious. 

The  knee-joint  and  ankle-joint  are  both  affected  by 
tuberculosis,  and  both  treated  by  rest  and  hygiene,  but 
the  results  of  healing  —  a  stiff  joint  —  are  much  more 
serious  in  the  knee  than  in  the  spine. 

These  are  all  long-standing  cases.  Any  social  worker 
dealing  with  tuberculosis  of  a  joint  knows  that  he  is 
concerned  with  a  chronic  case,  and  yet  a  hopeful  one. 
It  is  expensive  and  will  take  a  long  time,  but  the  time 
and  money  will  be  well  spent,  much  more  so  than  in 


DISEASES  OF  BONES  AND   JOINTS 

tuberculosis  of  the  lungs,  in  kidney  disease,  or  in  ar- 
teriosclerosis. I  always  feel  that  a  social  worker  who  is 
in  touch  with  tuberculosis  of  the  bones  under  condi- 
tions where  he  can  really  do  something,  has  a  very 
hopeful  and  really  encouraging  piece  of  work. 

Syphilis  of  the  bones,  like  tuberculosis,  has  certain 
favorite  spots.  No  one  knows  at  all  why  tuberculosis 
picks  out  the  hip  and  spine  especially,  and  no  one 
knows  why  syphilis  picks  out  the  forehead.  The  fore- 
head and  the  shin-bone  are  the  two  places  that  syphilis 
most  often  strikes.  Tuberculosis  is  almost  never  seen 
on  the  forehead,  but  a  long-standing  abscess  leading 
into  the  bone  on  the  forehead  means  practically  one 
thing  only.  The  diagnosis  is  by  Wassermann  reaction, 
by  history,  and  by  X-ray.  In  doubtful  cases  of  syphilis, 
X-ray  of  the  shin-bone,  even  when  it  has  been  healed 
long  ago,  helps  us  in  something  the  same  way  that  the 
Wassermann  test  does. 

There  is  no  direct  surgical  treatment ;  the  drug  treat- 
ment is  the  same  that  we  always  give  to  syphilis  wher- 
ever it  may  be.  There  is  no  reason  why,  under  proper 
treatment,  syphilis  of  the  bone  should  not  recover,  and 
in  general  it  does. 

Syphilis  of  the  joints  generally  presents  the  picture 
of  acute  rheumatism  —  hot,  swollen,  painful,  tender 
joints,  plus  a  positive  Wassermann  reaction.  This  dis- 
ease is  now  recognized,  as  it  rarely  was  until  we  had  the 
Wassermann  reaction,  and  is  cured  by  anti-syphilitic 
treatment. 

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Rickets  is  a  disease  of  the  bones  of  children ;  and  only 
of  children,  although  its  effects  last  on  into  adult  life. 
In  spite  of  an  immense  amount  of  work  done  upon  it, 
nobody  knows  its  cause.  Negro  children  have  it  with 
tremendous  frequency,  and  it  seems  to  occur  a  little 
more  often  in  the  poor  than  it  does  in  the  rich,  but  I 
have  seen  rickets  in  the  most  healthy  and  well-to-do 
families;  I  have  seen  it  in  a  newborn  baby  who  could 
not  have  been  fed  wrong  because  he  had  never  been 
fed  at  all;  so  that  I  think  there  is  still  a  good  deal  to 
learn  about  rickets.  We  have  a  general  belief  that  it 
has  something  to  do  with  bad  hygiene.  The  bad  hy- 
giene is  there  anyhow,  and  we  might  as  well  work 
against  it,  whether  it  has  anything  to  do  with  the 
rickets  or  not. 

Rickets,  like  other  diseases,  has  certain  bones  that  it 
is  fond  of,  namely,  the  bones  of  the  head,  ribs,  fore- 
arms, pelvis,  and  legs.  It  hits  all  the  bones  of  the  body, 
but  these  most.  The  rachitic  head  is  the  so-called  intel- 
lectual forehead.  There  are  many  familiar  scholastic 
figures  showing  it  in  this  part  of  the  country.  A  person 
may  have  a  very  capacious  brain  in  spite  of  rickets,  but 
there  is  no  special  connection  between  what  you  see  on 
the  outside  and  what  is  on  the  inside.  In  a  baby  the 
rachitic  head  is  much  more  striking  because  the  rest  of 
the  body  is  so  small.  The  head  may  be  bigger  than  the 
chest.  The  forehead,  as  I  have  said,  especially  bulges 
out  and  the  openings  on  the  top  and  back  of  the  head 
which  are  present  in  the  newborn  baby  do  not  close,  or 

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DISEASES  OF   BONES  AND  JOINTS 

close  very  late.  The  soft  spots  remain  there  long  after 
they  ought  to  have  hardened  up.  This  is  characteristic 
of  rachitic  bones  everywhere.  They  are  too  soft  and 
they  hinder  growth.  As  soon  as  the  baby  begins  to 
creep,  to  put  his  arms  down,  the  soft  arm  bones  begin 
to  bend  and  bow  outward,  and  as  soon  as  he  begins  to 
walk  he  begins  to  get  bow-legged  or  knock-kneed. 
The  rib  bones,  about  one  inch  outside  the  breast  bone, 
have  a  series  of  enlargements,  like  a  string  of  beads 
down  the  chest,  to  which  the  term  "rachitic  rosary" 
has  often  been  given. 

I  have  spoken  of  rickets  as  a  disease  of  the  bones 
because  it  is  in  the  bones  that  we  see  the  most  obvious 
changes,  but  it  affects  also  the  muscles.  The  rachitic 
child  is  pitifully  weak  in  all  his  muscles.  This  weak- 
ness is  often  mistaken  for  paralysis ;  but  the  baby  is  not 
paralyzed,  only  the  muscles  are  very  flabby.  As  a  re- 
sult of  the  flabbiness  of  his  abdominal  muscles  the  gas 
which  is  normally  present  in  his  intestine  distends 
the  abdomen  until  it  becomes  very  prominent.  We 
see  very  "large  stomachs"  on  most  rachitic  children. 
The  rachitic  child  often  has  fever,  and  in  his  febrile 
spells,  especially  at  night,  often  sweats  a  great  deal. 
He  is  also  a  very  restless  child,  and  we  often  find  that 
from  his  wriggling  the  hair  is  all  worn  off  the  back  of 
his  head.  His  mother  often  is  quite  sure  that  he  has 
worms,  and  when  we  ask  why,  we  find  that  it  is  be- 
cause he  grinds  his  teeth,  which  is  well  recognized 
among  mothers,  although  not  among  physicians,  as  a 

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symptom  of  worms.  If  a  child  grinds  his  teeth  and 
scratches  his  nose  and  has  a  big  appetite,  these  are 
supposed  by  mothers  to  be  symptoms  of  worms, 
though  none  of  them  has  anything  whatsoever  to  do 
with  worms. 

Rickets  gets  well  of  itself  in  the  vast  majority  of 
cases.  That  is  very  disconcerting  sometimes.  The  bow- 
legs,  for  instance,  for  the  cure  of  which  the  ortho- 
pedic physician  has  got  the  social  worker  to  persuade 
the  parents  to  buy  costly  apparatus,  straighten  out 
of  themselves  in  many  cases,  and  the  mothers  and 
fathers,  from  their  experience  with  previous  babies, 
are  very  apt  to  know  that  beforehand,  and  hence  are 
very  skeptical  in  taking  our  advice.  Why  this  spon- 
taneous recovery  occurs  we  do  not  know.  It  does  not 
occur  in  every  case,  otherwise  we  should  see  no  bow- 
legs.  But  the  fact  that  we  do  not  see  more  bow-legged 
adults  is  very  significant  in  view  of  the  fact  that  al- 
most every  child  is  bow-legged  at  some  time  and  in 
some  degree. 

The  thing  to  work  at  is  the  diet.  We  advise  a  diet 
with  the  proper  amount  of  fat,  which  is  apt  to  be  left 
out,  and  try  to  improve  hygiene  in  other  respects,  but 
I  do  not  think  we  yet  know  much  about  it.  The  only 
danger  of  the  disease  is  that  it  weakens  the  child  gen- 
erally. He  is  more  likely  to  catch  any  disease  that  is 
going,  and  hence  a  great  many  of  these  children  die  of 
pneumonia  or  of  some  germ  disease  when  they  would 
not  if  they  had  not  had  rickets.  It  is  a  fair  guess  that 

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DISEASES  OF  BONES  AND  JOINTS 

the  cause  of  rickets  will  finally  be  proved  to  be  in  the 
ductless  glands. 

Questions  and  Answers 

Q.  When  the  cartilages  change  to  bone,  would  that  be  the 
time  when  the  bones  straighten  out? 

A.  I  do  not  see  how  it  can  be.  That  change  is  going  on 
through  childhood  and  into  adult  life,  way  into  the  forties 
and  fifties.  In  the  ribs  the  ossification  of  cartilage  goes  on 
clear  up  to  the  time  of  death. 

Q.  Can  you  straighten  the  limbs  by  rubbing? 

A.  Not  so  far  as  I  know.  They  can  be  helped  by  appara- 
tus and  by  operation;  I  should  not  suppose  that  rubbing 
would  do  much. 

Q.  Can  rickets  be  avoided  by  prenatal  care? 

A.  I  do  not  know  any  evidence  by  which  I  can  answer 
that  question.  Prenatal  supervision  has  not  yet  been  carried 
out  on  a  scale  large  enough  to  give  us  any  knowledge  as  to  its 
power  to  prevent  rickets. 


CHAPTER  XIII 

DISEASES  OF  THE  BONES  AND  JOINTS   (CONTINUED) 
DISEASES   OF  THE   MUSCLES 

ANY  one  who  sees  a  patient  with  a  fracture,  and  wants 
to  do  what  he  can  in  the  way  of  first  aid,  has  a  very 
definite  duty  so  far  as  he  can  perform  it,  which  is  to  put 
a  pillow  around  the  affected  part.  The  essential  thing 
is  to  put  the  arm  or  the  leg  down  upon  a  pillow  length- 
wise, pull  the  pillow  up  around  it  and  bind  it  on  tightly. 
That  makes  as  good  a  splint  and  as  comfortable  as  we 
can  improvise.  When  a  leg  has  been  put  in  a  pillow 
in  that  way  we  can  take  hold  of  the  folded  ends  of  the 
pillow  above  the  leg  and  lift  the  leg  by  the  pillow  in  a 
way  that  is  much  more  comfortable  to  the  patient  than 
anything  else  we  can  do. 

It  is  important  to  recognize  that  there  is  no  good 
diagnosis  of  fractures  in  modern  times  except  X-ray 
diagnosis.  We  see  a  good  many  fractures  which  are 
not  diagnosed  in  that  way,  but  we  see  their  ill  results 
also.  If  the  patient  can  possibly  get  to  a  place,  there- 
fore, where  a  good  X-ray  diagnosis  can  be  made,  that 
is  what  is  to  be  desired. 

The  long  time  which  has  to  be  allowed  for  the  heal- 
ing of  a  fracture  is,  I  suppose,  familiar  to  most  of 
my  readers.  We  have  to  allow  three  to  twelve  weeks. 

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DISEASES  OF  BONES  AND  JOINTS 

That  is  about  as  well  as  I  can  put  it  for  the  full  healing 
of  a  fracture.  It  should  be  added,  however,  that  if  the 
fracture  is  properly  set,  the  leg  or  the  arm  is  just  as 
strong  as  it  was  before.  The  fractures  which  are  the 
most  likely  to  leave  trouble  are  the  fractures  of  the 
wrist.  Colles's  fracture  of  the  radius  is,  if  not  set  just 
right,  very  apt  to  leave  some  stiffness  and  deformity 
of  the  wrist.  A  good  deal  can  be  done  for  that  by  mas- 
sage or  by  passive  motion.  It  is  a  bad  disability  in  a 
case  not  properly  set. 

Fractures  of  the  thigh  are  sometimes  bothersome  to 
treat  because  of  the  difficulty  of  keeping  the  two  ends 
of  the  bone  together.  The  upper  end  of  the  bone  is 
pulled  up  by  the  psoas  muscle  and  fastened  in  position, 
and  in  consequence  we  find,  quite  usually  in  children's 
hospitals,  a  baby  with  his  heel  pointing  to  heaven,  — 
his  leg  supported  perpendicularly,  —  as  that  is  the 
only  way  the  two  ends  of  the  bone  can  be  kept  to- 
gether. The  child  gets  perfectly  used  to  it,  and  can 
sleep  in  this  position. 

Fractures  of  the  skull  are  a  very  common  cause  of 
death  in  accidents  and  after  falls.  The  evidence  neces- 
sary for  the  diagnosis  of  fractured  skull  is  often  hard  to 
get.  There  is  usually  a  big  bruise  on  the  outside,  and 
through  the  bruise  the  doctor  can  feel  nothing.  Here 
again  X-ray  is  the  essential  thing.  X-ray  shows  up 
fractures  of  the  skull  which  are  impossible  to  feel,  and 
impossible  to  detect  by  any  other  method.  I  am  sure 
we  have  made  many  wrong  diagnoses  for  lack  of  this 

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help  in  the  past.  I  refer  now  to  fractures  of  the  vault, 
the  upper  part  of  the  skull.  It  is  essential  that  frac- 
tures of  the  vault  of  the  skull  should  be  diagnosed, 
because  if  the  broken  bone  is  pressing  upon  the  brain 
the  pressure  may  be  relieved  and  can  be  relieved  by  an 
operation  which  lifts  the  bone.  About  as  common  are 
fractures  of  the  base  of  the  skull,  in  which  the  most 
important  evidence  is  bleeding  from  the  ear.  In  a 
person  who  has  had  a  fall  upon  the  head  and  bleeds 
from  the  ear,  there  is  probably  a  fracture  of  the  base 
of  the  skull.  These  are  very  serious  and  most  of  them 
fatal. 

I  have  spoken  of  the  necessity  of  X-ray  in  fractures. 
Of  course  it  is  equally  essential  in  injuries  that  may  be 
fractures,  that  is,  in  bad  sprains.  It  happens  again  and 
again  that  an  injury  is  treated  as  a  sprain  and  does  not 
heal ;  later  X-ray  shows  that  it  was  a  fracture  unrecog- 
nized. Sprains  that  are  more  than  usually  serious,  or 
that  do  not  heal  properly,  should  always  be  suspected 
of  being  fractures  and  should  be  X-rayed. 

Joint  Disease 

Arthritis  is  a  very  general  term,  includes  all  types  of 
joint  trouble,  and  is  not  in  itself  serious.  There  are 
very  slight  forms  of  arthritis;  a  sore  joint  means  the 
same  thing  in  less  formidable  terms. 

We  recognize  five  types  of  arthritis,  with  some  sub- 
divisions under  those  main  types :  — 

(i)  Infectious  arthritis,  due  to  a  germ. 

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DISEASES  OF  BONES  AND  JOINTS 

(2)  Hypertrophic   arthritis,    which   means   arthritis 
with  an  overgrowth  of  bone. 

(3)  A  trophic  arthritis,  which  means  that  the  bone 
shrivels  or  goes  to  pieces,  so  that  the  ends  of  the  bones 
telescope  into  each  other. 

(4)  Gouty  arthritis. 

(5)  Traumatic  arthritis,  that  due  to  an  injury. 

In  the  Out- Patient  Department  of  the  Massachu- 
setts General  Hospital  there  were  treated  in  1915:  — 

Infectious  Arthritis 372  cases 

Hypertrophic  Arthritis 122 

Atrophic  Arthritis 7 

Subdividing  infectious  arthritis,  which  is  far  the 
commonest,  —  fully  three  times  as  common  as  any  of 
the  rest,  —  we  have  in  the  first  place  one  type  which 
we  have  already  dealt  with  and  finished,  tuberculous 
arthritis  —  tuberculous  joint  disease.  Then  we  have 
the  acute  streptococcus  arthritis,  which  we  call  rheu- 
matic, a  rather  uncommon  disease,  although  the  term 
is  very  frequently  used  for  what  is  not  rheumatism. 
Acute  streptococcus  rheumatism  is  the  same  as  rheu- 
matic fever.  It  is  the  type  which  I  have  already  men- 
tioned as  associated  with  heart  trouble,  and  with  ton- 
sillitis, and  with  pus  foci  about  the  teeth  or  anywhere 
else.  This  is  an  acute,  self-limited  disease,  has  a  be- 
ginning, middle,  and  generally  an  end  within  a  few 
days  or  weeks.  The  best  thing  that  we  have  to  say 
about  it  is  that,  while  it  may  be  very  painful,  it  leaves 
the  joints  sound  in  the  end.  It  does  not  cripple  the 

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joints.  We  are  accustomed  to  hearing  of  people  "crip- 
pled by  rheumatism";  they  are  not;  they  are  crippled 
by  something  else.  Rheumatism  passes  off  as  an  acute 
attack  and  that  is  the  end  of  it  so  far  as  the  joints  are 
concerned.  It  may  recur,  especially  if  we  have  not  got 
rid  of  the  foci  in  the  teeth,  tonsils,  or  elsewhere.  But 
it  is  in  the  heart  that  we  are  most  afraid  of  the  strepto- 
coccus. The  group  of  drugs  called  the  salicylates,  or 
aspirin,  which  is  a  first  cousin,  give  us  great  relief  of 
pain  in  this  disease.  They  do  not  cure  it ;  they  do  not 
shorten  the  duration  of  illness;  they  do  not  protect  the 
heart ;  they  do  nothing  except  check  pain ;  but  that  is 
a  good  deal.  They  have  been  a  great  blessing  to  us, 
making  it  unnecessary  to  use  morphine  and  such  drugs, 
as  was  formerly  the  custom. 

This  type  of  disease  may  be  of  any  degree  of  sever- 
ity, from  a  little  joint  twinge  to  a  very  painful  illness 
lasting  weeks.  Any  infectious  disease  may  attack  the 
joints,  but  the  only  common  causes  are  the  germs  of 
rheumatism,  of  gonorrhea,  and  of  syphilis. 

Gonorrheal  arthritis  is  only  one  type  of  infectious 
arthritis,  but  differs  so  much  from  the  rest,  and  is  so 
characteristic,  that  we  all  ought  to  know  something 
about  it.  It  is  often  called  "gonorrheal  rheumatism." 
I  have  tried  to  indicate  that  the  word  "rheumatism" 
ought  to  be  kept  for  one  rather  uncommon  disease  due 
to  a  streptococcus.  Two  to  five  per  cent  of  cases  of  gon- 
orrhea have  an  infection  of  the  joints  as  part  of  their 
course.  As  a  rule  it  is  confined  or  severest  in  one  joint, 

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DISEASES  OF  BONES  AND  JOINTS 

or  at  most  in  two,  whereas  rheumatic  arthritis  in  the 
strict  sense  is  practically  never  confined  to  one  or  two 
joints,  and  attacks  a  dozen  or  more  in  almost  every 
case.  Gonorrheal  arthritis  rarely  begins  in  the  fingers 
or  toes,  but  generally  attacks  a  large  joint,  such  as  the 
knee  or  the  ankle ;  rheumatic  arthritis  generally  begins 
in  the  fingers  or  toes.  Gonorrheal  arthritis  is  a  very 
slow,  tedious  affair,  and  although  the  bones  themselves 
are  not  at  all  affected,  the  tendons  around  the  joint 
may  be  inflamed  enough  to  leave  some  stiffness  in  the 
end.  It  is  much  more  serious  in  its  results  than  the 
rheumatic  type,  and  much  slower  in  healing. 

Q.  Which  type  do  they  treat  with  serum? 

A.  The  gonorrheal,  but  this  treatment  is  not  widely  used 
now  because  we  do  not  any  longer  believe  that  it  does  any 
good. 

Hypertrophic  arthritis,  the  next  most  common  type, 
is  a  disease  of  people  past  middle  life,  —  one  almost 
never  sees  it  before  forty.  After  forty  it  is  the  com- 
monest and  most  harmless  type,  a  fact  which  it  is  of 
importance  for  us  all  to  know.  This  is  the  type  that 
makes  the  last  joints  of  the  fingers  enlarge.  It  is  usu- 
ally confined  to  those  joints,  gives  little  pain,  and 
aside  from  appearances  is  of  little  account  there. 

In  horses  this  disease  is  called  "ring  bone'*;  it  pro- 
duces stiffening.  If  we  try  to  bend  the  joint,  before 
long  the  end  of  this  projecting  bone  will  strike  the  end 
of  the  next  one,  and  prevent  the  part  from  bending 
as  it  should.  When  this  happens  in  the  fingers  we  call 

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it  Heberden's  nodes,  and  make  light  of  it.  But  in  other 
bones  it  has  more  serious  consequences. 

In  the  knee  joint  exactly  the  same  disease  confronts 
us,  and  is  of  a  great  deal  more  importance.  It  pro- 
duces pain  and  stiffness,  and  from  time  to  time  a 
pouring  out  of  serum,  called  "water  on  the  knee," 
from  the  banging  of  one  of  those  projecting  bones 
against  another.  In  the  hip  joint  this  gives  more 
trouble  still,  and  makes  there  what  is  called  the  "old 
man's  hip  disease."  The  young  man's  hip  disease  is 
tuberculosis;  the  old  man's  hip  disease  is  just  this. 
The  hip  joints  into  the  pelvis  at  a  right  angle,  and  at 
the  end  of  the  joint,  where  it  ought  to  fit  in,  this  over- 
growth occurs,  pries  the  hip  out  of  its  socket,  and  so 
makes  it  impossible  for  it  to  move  freely  in  its  socket. 
There  results  a  stiff,  painful  hip  which  may  cripple  the 
individual  a  good  deal. 

We  see  this  same  disease  also  in  the  spine;  there  it 
causes  a  stiff  back  with  more  or  less  pain,  pain  follow- 
ing the  ribs,  because  these  spicules  of  bone  press  upon 
nerves  which  run  along  parallel  to  the  ribs.  It  is  in  this 
field  that  the  osteopaths  have  the  grain  of  truth  in 
their  theory  that  the  misplacement  or  pressure  of  bones 
upon  nerves  is  the  cause  of  all  disease.  As  with  home- 
opathy and  many  other  theories  of  true  but  limited 
application,  the  trouble  comes  when  one  attempts  to 
apply  it  everywhere.  The  osteopaths  do,  nevertheless, 
a  deal  of  good ;  their  theory  is  wrong,  but  their  prac- 
tice helpful  in  well-selected  cases. 

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DISEASES  OF  BONES  AND  JOINTS 

In  very  serious  cases  of  hypertrophic  arthritis  in  the 
hip,  an  operation  is  done  to  chisel  off  the  projecting 
pieces  of  bone.  This  is  not  so  far  a  very  successful 
operation,  but  sometimes  better  than  nothing.  Else- 
where in  the  body  medical  science  has  not  yet  found 
anything  effective  to  do  about  hypertrophic  arthritis. 
We  support  the  spine,  and  give  some  relief  by  prevent- 
ing the  movements  of  bones  upon  one  another,  but  we 
do  not  cure  it  anywhere.  It  is  a  long-standing  disease; 
people  often  have  it  twenty  years  or  more. 

The  next  variety,  atrophic  arthritis,  is  very  fortu- 
nately rare.  We  had  in  1915  at  the  Massachusetts 
General  Hospital  only  seven  cases  as*  against  four 
hundred  and  ninety-four  of  the  other  types.  It  is  the 
most  crippling,  the  most  terrible  of  all  the  forms  of 
joint  disease.  It  starts  usually  in  the  second  joints  of 
the  fingers,  and  causes  "spindle  fingers,"  usually  in 
young  people,  more  often  in  girls  than  in  boys.  Start- 
ing in  the  knuckle  joints  it  progresses  toward  the  centre 
of  the  body.  When  it  gets  into  a  joint  it  never  leaves 
it,  and  when  it  has  been  long  in  a  joint  it  always  stif- 
fens it,  locks  it,  and  in  the  end  we  may  get  general 
ossification  —  the  "ossified  men"  such  as  are  shown 
in  circuses.  It  may  lock  the  jaw  so  that  the  patient 
cannot  open  his  mouth  and  must  have  his  teeth  out 
so  that  he  can  be  fed.  Treatment  makes  not  the  slight- 
est difference.  Luckily  it  is  very  rare ;  we  have  not  any 
idea  of  its  cause. 

It  is  these  last  two  types,  then,  that  make  the  crip- 

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pling  joint  troubles;  the  last  terrible,  the  first  bother- 
some. 

Q.  In  which  of  these  classes  belong  the  people  who  are 
fast  in  chairs  for  years? 

A.  To  the  last  I  should  say;  the  people  who  can't  do  for 
themselves,  have  to  be  fed. 

Q.  What  is  it  that  atrophies? 

A.  The  joint  itself;  the  bones  telescope.  In  long-standing 
cases  the  hands  are  drawn  out  of  shape  and  you  get  the 
"flipper  hand"  which  in  any  almshouse  you  see  so  much. 

Gout  is  a  rare  disease ;  I  have  not  seen  a  case  to  recog- 
nize it  in  three  years.  I  am  speaking  now  of  America; 
if  we  go  to  England  we  can  hear  it  upon  every  one's 
tongue,  and  mere  we  are  asked  to  believe  that  it  is  a 
very  common  disease.  I  always  warn  people  going  to 
England  that  if  they  have  any  disease  over  there,  they 
will  be  sure  to  be  told  that  it  is  .gout,  but  that  they 
must  not  believe  it.  One  hears  in*  England  of  gouty 
asthma,  gouty  kidneys,  eczema,  etc.  There  is  no  scien- 
tific basis  for  these  terms  at  the  present  time.  Gout 
means  a  disease  of  bone  and  of  tendon.  Diagnosis  can 
be  verified  only  by  X-ray.  We  do  not  know  its  cause ;  it 
is  always  associated  in  the  minds  of  the  laity  with  high 
living,  especially  with  port  wine,  but  we  do  not  know 
this  to  be  true.  I  have  seen  gout  in  the  most  abstemi- 
ous maiden  ladies.  It  is  probably  hereditary,  and  the 
in-breeding  of  families  makes  it  come  down  in  a  certain 
line.  As  we  know  from  literature,  it  is  prone  to  attack 
the  big  toe,  coming  on  with  furious  pain  in  the  night, 

^-    4   '• 

easing  up  the  next  day,  worse  again  the  next  night,  and 

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DISEASES  OF   BONES  AND   JOINTS 

so  on  for  four  or  five  days,  after  which  that  particular 
attack  is  gone.  That  is  acute  gout. 

Chronic  gout  is  the  deposition  in  the  joints  of  what 
are  called  "chalk-stones,"  the  bi-urate  of  sodium, 
which  grows  out  in  under  or  through  the  skin,  so  that 
there  is  a  tradition  of  a  gentleman  who  could  write  his 
name  on  the  blackboard  with  the  chalk  in  his  fingers. 
These  chalky  deposits  also  appear  in  the  lobe  of  the 
ear.  They  are  hard,  gritty,  different  from  anything 
else,  and  easily  recognized. 

The  disease  is  very  intractable.  Treatment  is  un- 
satisfactory. 

Traumatic  arthritis,  or  the  inflammation  about  a 
joint  from  injury,  is  the  ordinary  "  water  on  the  knee," 
but  we  see  the  same  thing  in  the  elbow,  the  ankle,  or 
the  wrist,  if  there  has  been  injury  to  these  joints.  A 
wrench  or  a  blow  starts  up  the  irritation  in  the  joint 
and  serum  is  poured  out,  the  joint  swells  and  fills  with 
fluid. 

Q.  Is  that  the  same  as  the  synovial  fluid? 
A.  Yes.  It  is  an  excess  of  the  synovial  fluid,  the  lubricat- 
ing fluid  which  is  in  all  true  joints. 

The  only  important  thing,  I  think,  to  be  said  about 
this  disease  is  that,  under  modern  treatment  which 
does  not  confine  the  patient  to  bed  in  a  plaster  cast,  its 
duration  is  now  much  shorter  than  it  used  to  be.  I  can 
well  remember  in  my  childhood  that  the  family  drew 
very  long  faces  in  cases  called  "water  on  the  knee." 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

The  same  thing  is  now  treated  by  keeping  quiet  for  a 
few  days,  and  the  person  is  then  advised  to  move,  be- 
cause moving  helps  the  circulation  and  so  helps  the 
healing.  I  do  not  know  any  disease  in  the  treatment  of 
which  we  have  made  more  progress  of  late  years.  The 
joint  should  not  be  kept  quiet  long  and  must  not  be 
put  in  a  plaster  cast ;  it  is  much  better  for  exercise  after 
the  first  forty-eight  hours.  To  relieve  pain  in  any  such 
injury  one  tries  heat  and  cold,  and  only  by  experiment 
can  one  tell  which  will  help  the  individual  sufferer 
most.  I  should  say  that  the  majority  get  more  relief 
from  heat.  That  is  the  only  treatment  necessary,  al- 
though if  the  pain  is  severe  the  patient  may  need  some 
drug  for  the  control  of  it  for  the  first  day  or  two.  After 
that  the  joint  is  strapped  with  adhesive  plaster  and 
the  patient  is  advised  to  use  it  cautiously,  but  in  spite 
of  pain. 

'  Villous  Arthritis  "  is  a  term  often  used.  It  refers 
to  the  fact  that  mill  or  fringes  of  joint  membrane  may 
develop  profusely  in  the  course  of  any  chronic  joint- 
infections,  hypertrophic  or  other.  Villous  arthritis  is 
not  a  separate  type.  The  villi  are  sometimes  trouble- 
some and  operations  for  their  removal  are  done  with 
tolerable  success. 

Questions  and  Answers 

Q.  Is  hypertrophic  or  atrophic  arthritis  hereditary? 
A.  Not  so  far  as  I  know;  I  have  heard  no  good  evidence 
that  either  of  these  is  hereditary. 
Q.  What  is  arthritis  deformans  ? 

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DISEASES  OF  BONES  AND  JOINTS 

A.  It  is  not  a  good  term ;  it  means  any  type  of  arthritis 
which  ends  in  a  deformity.  Gout  produces  deformity;  hy- 
pertrophic  arthritis  deforms  the  fingers  and  the  hip ;  but  the 
most  fearful  deformities  are  generally  those  due  to  atrophic 
arthritis.  We  cannot  tell  from  the  term  arthritis  deformans 
what  disease  we  are  dealing  with. 

When  we  hear  that  a  person  has  "arthritis,"  we  know 
almost  nothing  except  that  there  is  something  wrong  in  his 
joints,  which  may  be  anything  from  a  slight  annoyance  to  a 
crippling  disease.  We  always  need  to  know  what  is  the  type 
of  arthritis  and  often  we  cannot  find  out,  because  there  has 
not  been  an  X-ray,  and  without  an  X-ray  no  human  being 
can  tell.  There  is  no  field  of  medicine  in  which  X-ray  is  so 
essential  as  in  disease  of  the  bones  and  joints.  X-ray  of  the 
infectious  type  shows  nothing  in  the  joints;  the  bone  is  all 
right.  The  second  type  shows  the  outgrowths  which  I  have 
sketched,  and  the  third  an  atrophy  and  telescoping  of  bones. 

J 

Osteomyelitis,  or  inflammation  starting  in  the  bone 
marrow,  is  of  two  types,  the  septic  and  the  tuberculous. 
The  tuberculous  we  have  already  covered  well  enough 
in  what  I  have  said  about  tuberculosis  of  the  bones  and 
joints.  Septic  osteomyelitis  is  chiefly  a  disease  of  chil- 
dren. I  do  not  know  of  a  case  that  has  begun  in  a 
person  past  thirty  years;  the  great  majority  begin  in 
boys  under  fifteen.'  They  constitute  one  of  the  enor- 
mous group  of  cases  miscalled  "rheumatism,"  and  mis- 
treated in  consequence.  The  boy  has  a  pain  about  a 
joint;  if  it  is  not  called  a  "growing  pain,"  it  may  be 
called  "rheumatism,"  and  if  it  is  called  either  it  is  apt 
to  be  neglected,  for  the  treatment  of  these  things  is 
surgical  and  should  be  begun  early  if  it  is  to  be  success- 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

ful.  Pus  forms  deep  in  the  bone  near  a  joint,  and  the 
pain  from  it  may  be  intense. 

If  it  is  diagnosed  and  promptly  treated  by  cutting 
down  and  letting  the  pus  out,  it  may  amount  to  little. 
If,  as  is  unfortunately  common,  it  is  not  recognized, 
one  of  two  things  happens.  Either  it  spreads  into  the 
blood  with  fatal  blood  poisoning,  or  more  commonly  it 
burrows  about  in  the  bone  and  eats  out  the  bony  tis- 
sues until  a  large  part  of  the  shin  bone  or  the  thigh  bone 
may  be  honeycombed  along  the  track  where  the  pus 
has  worked  its  way.  In  ordinary  hospital  work  what 
we  see  are  the  end-results.  Years  before  a  child  has  had 
acute  neglected  osteomyelitis,  and  the  pus  has  finally 
worked  its  way  to  the  surface,  leaving  a  discharging 
sinus  —  that  is,  an  opening  leading  frpm  the  skin  down 
to  the  bone.  An  operation  is  done,  the  dead  bone  is 
chiselled  out,  and  in  favorable  cases  the  whole  thing 
heals  up. 

More  often  the  trouble  recurs,  and  operation  after 
operation  is  done.  Ten  or  a  dozen  operations  are  done 
on  the  same  child  sometimes,  in  the  attempt  to  get  rid 
of  this  trouble.  If  the  child  survives  his  earlier  years, 
he  is  apt  to  outgrow  the  disease;  that  is,  the  suppura- 
tion is  apt  to  heal  up  if  he  can  get  by  the  twentieth  or 
twenty-fifth  year.  These  are  very  tedious,  disappoint- 
ing cases,  with  chronic  invalidism  for  years,  and  yet 
never  hopeless.  At  any  time  the  child's  vitality  may 
get  the  best  of  the  infection,  or  a  final  operation  may 
stop  the  trouble.  Very  interesting  operations  are  done 

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DISEASES  OF  BONES  AND  JOINTS 

in  replacing  one  bone  with  another.  Bits  of  bone  are 
taken  from  a  healthier  individual  or  animal,  some- 
times, or  from  another  part  of  the  same  individual,  and 
put  into  the  place  where  he  needs  bone.  This  is  all  still 
in  the  experimental  stage.  The  disease  is  generally  con- 
fined to  one  bone,  and  does  not  appear  in  other  places, 
but  we  cannot  make  an  absolute  rule  about  that. 

Sacro-iliac  Strains  or  Sprains  —  Loose  Sacro-iliac  Joint 

The  lowest  piece  of  the  spine  above  the  coccyx  is 
composed  of  several  vertebrae  fused  into  each  other  to 
make  a  single  bone,  called  the  sacrum.  That  bone  fas- 
tens on  each  side  to  the  pelvis,  by  an  irregular  unsatis- 
factory joint  which  is  not  well  supported  and  which 
is  very  apt  to  get  into  trouble  one  way  or  another.  Ex- 
actly what  happens  to  it  I  do  not  think  any  two  people 
are  agreed.  Something  happens,  strains  or  sprains  or 
slipping  or  loosening,  whereby  there  is  often  much  pain 
around  that  region.  A  good  deal  of  backache  and  many 
cases  falsely  called  lumbago  are  due  to  sacro-iliac  le- 
sions. (Lesion  is  the  most  indefinite  of  terms.  When  I 
speak  of  a  sacro-iliac  lesion,  I  mean  that  I  do  not  know 
—  I  am  doubtful  if  any  one  knows  —  what  the  trouble 
is.)  The  probability  is  that  all  the  troubles  of  other 
joints  occur  there,  all  forms  of  arthritis,  all  sprains  and 
injuries  that  happen  to  other  joints,  but  it  is  a  joint 
very  difficult  to  examine  by  X-ray  or  in  any  other  way, 
so  that  we  are  very  seldom  able  to  say  exactly  what  is 
going  on.  In  some  cases  there  is  an  obvious  strain:  a 

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man  takes  a  trunk  on  his  back,  for  instance,  feels  a 
sudden  pain,  a  sense  that  something  has  given  way, 
and  at  once  feels  a  severe  backache.  In  such  cases  we 
feel  pretty  sure  that  the  bones  of  the  joint  have  slipped 
past  each  other.  In  other  cases  there  is  no  such  history ; 
a  person  just  begins  to  feel  pain  in  the  sacro-iliac  joint. 
A  good  many  women  have  it  after  childbirth,  and  then 
it  seems  that  there  must  be  some  stretching  of  the 
bones  in  the  process  of  parturition.  Occasionally  when 
a  doctor  takes  hold  of  the  pelvis  he  can  move  the  joint, 
—  it  should  be  impossible  to  move  it,  —  and  feel  that 
there  is  a  loosening  or  slackening  in  it. 

The  disease  is  greatly  helped  by  the  right  kind  of 
support,  and  is  not  helped  at  all  by  drugs.  We  often 
do  not  know  exactly  what  is  the  matter  but  we  do 
know  what  to  do,  namely,  to  give  the  joint  the  right 
kind  of  support  —  by  strapping  with  plaster  or  by  the 
right  kind  of  belt,  or  by  the  right  kind  of  corset.  Of 
late  years  corsets  are  more  and  more  used,  but  of 
course  the  distinction  between  a  light  belt  and  a  heavy 
corset  is  not  important.  All  these  press  the  pelvis  in- 
ward from  the  sides  so  as  to  prevent  free  motion  of  the 
sacro-iliac  joint. 

In  a  good  many  cases  this  sacro-iliac  trouble  is 
linked  up  with  sciatica;  that  is,  with  pain  down  the 
back  of  the  leg.  We  used  to  say  that  the  sciatic  nerve 
was  in  some  way  pressed  upon  by  a  dislocation  of  the 
sacro-iliac  joint.  That  has  not,  I  think,  been  shown  to 
be  true,  and  the  best  we  can  say  is  that  the  two,  sciatica 

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DISEASES  OF  BONES  AND  JOINTS 

and  sacro-iliac  lesions,  are  often  in  some  way  related, 
and  that  the  treatment  of  the  joint  by  strapping  or 
corsets  may  help  the  sciatica  very  much.  , 

Scoliosis  is  a  term  usually  reserved  for  very  severe 
cases  of  spinal  curvature  combined  with  twist;  the 
spine  is  both  curved  and  rotated  upon  its  axis.  This  is 
to  be  distinguished  from  the  less  degree  of  curvature 
which  people  often  do  not  discover  and  which  often 
should  be  discovered  or  treated.  Scoliosis  is  a  severe 
disease  and  must  be  treated.  Scoliosis  seems  usually 
to  be  due  to  some  congenital  change  in  the  bones, 
something  wrong  in  the  way  the  bones  are  made  in  the 
bottom  of  the  spine.  We  can  get  at  this  by  X-ray. 
Scoliosis  has  no  relation  to  any  infectious  disease,  to 
any  disease  of  the  heart,  lungs,  or  to  tuberculosis.  It 
is  apparently  an  anomaly  of  the  bones  themselves.  If 
nothing  is  done,  the  tendency  of  the  disease  is  to  get 
worse. 

It  is  treated  by  an  attempt  to  straighten  the  spine, 
or  at  any  rate  to  prevent  it  from  getting  more  and 
more  curved.  That  is  accomplished,  so  far  as  it  can  be 
accomplished,  by  jackets  and  supports,  which  bring 
pressure  upon  the  side  that  bulges  out.  The  treatment 
is  painful,  wearing,  and  tedious.  I  have  no  reliable 
knowledge  of  the  present  attitude  of  orthopedic  physi- 
cians as  to  the  results  of  this  treatment ;  I  know  that  of 
late  years  they  have  been  somewhat  uncertain  about 
its  value.  Social  workers  should  know  that  it  is  very 
important  to  find  out,  before  we  urge  a  prolonged  and 

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expensive  treatment,  whether  the  patient  will  stick  to 
it.  There  are  people  who  will  wear  a  scoliosis  jacket 
and  people  who  won't.  I  suppose,  in  a  general  way,  it  is 
the  more  phlegmatic,  patient  people  who  will  wear  a 
jacket,  and  the  more  nervous  people  who  will  not.  It 
is  hard  to  tell,  but  we  often  can  judge  from  our  knowl- 
edge of  temperament  whether  the  patient  will  wear  a 
jacket  or  not.  After  a  certain  number  of  these  plaster 
jackets  have  been  put  on  and  taken  off  again,  one 
finally  comes  down  to  some  sort  of  permanent  appa- 
ratus which  the  person  wears  more  or  less  steadily  for 
life. 

Pronated  Feet  ("Flat  Foot  ") 

Flat  foot.  Although  muscles  and  ligaments  have 
more  to  do  with  flat  foot  than  the  bones  themselves,  it 
is  convenient  to  include  it  here. 

When  the  muscles  that  should  hold  the  foot  straight 
are  too  weak,  the  ankle  slumps  inward,  the  inner 
ankle  bone  comes  too  near  to  the  ground  and  the  liga- 
ments (unable  without  help  from  the  muscles  to  hold 
up  the  foot)  stretch  so  as  to  let  the  bones  become  dis- 
placed. There  results  pain  in  the  instep  or  on  the  inner 
side  of  the  foot.  Walking  and  standing  increase  pain. 
This  pain  may  spread  up  the  leg,  even  above  the 
knee. 

Apparently,  then,  the  whole  trouble  starts  from 
weakness  in  one  set  of  muscles.  These  in  turn  may  be 
weakened  by  germ  diseases  (like  rheumatism),  by  over- 

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DISEASES  OF  THE   MUSCLES 

use,  by  strain  of  great  weight  (obesity)  on  them,  and 
by  a  good  many  other  causes  which  we  do  not  know. 

The  treatment  should  be  supervised  by  an  orthope- 
dist. Muscular  exercise,  proper  shoes,  and  sometimes 
plates  are  the  main  remedies. 

Bunions.  When  people's  feet  grow  out  of  shape, 
largely  as^a  result  of  bad  shoes,  the  rubbing  of  the  shoe 
upon  a  projecting  knob  of  displaced  bone  (oftenest  at 
the  base  of  the  great  toe)  results  in  an  inflammation 
when  the  friction  is  most  severe. 

The  treatment  is  proper  shoes  —  giving  room  enough 
for  the  toes  without  cramping  them.  This  will  prevent 
most  cases  and  will  give  reasonable  comfort  even  after 
the  bunion  has  formed  —  provided  we  are  not  too 
squeamish  as  to  appearance  and  are  ready  to  make 
room  for  the  excrescence. 

In  an  extreme  case  an  operation  may  be  done,  but 
the  amount  of  bother  attendant  on  the  operation  and 
its  results  is  sometimes  greater  than  the  annoyance  of 
the  bunion  itself. 

Diseases  of  the  Muscles 

So  large  a  portion  of  our  body  is  composed  of  muscle 
that  it  is  rather  remarkable  that  there  are  practically 
no  diseases  of  the  muscles  that  we  know  anything 
about  —  indeed,  there  is  only  one  disease  that  is  well 
understood,  trichiniasis. 

Trichiniasis  is  the  disease  that  we  may  get  if  our 
pork  is  not  properly  inspected  when  it  is  killed.  It  is  to 

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avoid  this  that  our  Government  goes  to  the  trouble 
and  expense  of  inspecting  pork.  People  who  eat  pork, 
especially  those  who  eat  it  raw  or  partially  cooked,  are 
more  or  less  liable  to  trichiniasis.  Until  our  inspection 
is  a  good  deal  more  perfect  than  it  is  yet,  this  will  al- 
ways be  so.  People  get  trichinae  from  sausages  now  and 
then,  because  they  often  contain  a  good  deal  of  un- 
cooked pork.  The  trichina  is  a  little  worm  which  gets 
into  the  muscles  —  hundreds  or  thousands  of  them 
scattered  all  through  the  body  —  and  produces  a  good 
deal  of  fever  with  soreness  and  tenderness  in  the  mus- 
cle, which,  with  the  characteristic  changes  in  the  blood, 
ought  to  make  diagnosis  clear.  Possibly  salvarsan  may 
help.  Otherwise  we  have  no  treatment;  we  have  to 
stand  by  and  look  on  until  the  patient  is  better.  Re- 
covery is  almost  always  complete,  but  takes  months. 

We  know  of  no  such  disease  as  "  muscular  rheuma- 
tism."' The  laity  know  it  well,  but  the  physicians  do 
not  recognize  it.  There  are  all  sorts  of  muscular  pains. 
Probably  the  commonest  is  stiff  neck.  Most  of  us  at 
some  time  have  felt  over  the  side  and  back  of  the  neck 
and  down  toward  the  shoulders,  a  stiffness  with  pain 
which  is  apparently  in  the  muscle.  Nobody  knows 
what  it  is  nor  what  causes  it.  Damp  weather  seems  to 
bear  some  relation  to  it.  It  goes  off  within  a  few  days 
or  at  most  a  week  or  two.  It  is  benefited  by  heat  and 
by  massage,  and  that  is  all  we  know  about  it.  Precisely 
the  same  disease,  when  it  attacks  the  muscles  lower 
down  in  the  back,  is  called  lumbago.  People  often 

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DISEASES  OF  THE   MUSCLES 

have  the  two  together,  and  that  makes  it  easier  to  dif- 
ferentiate this  from  other  diseases.  Any  such  pain  that 
persists  longer  than  a  week  or  ten  days  is  probably  due 
to  some  disease  of  the  bones  or  joints. 

Animal  Parasites 

The  commonest  of  these  is  tapeworm.  In  most 
parts  of  the  United  States  we  see  only  two,  the  tape- 
worm that  grows  in  beef  and  that  growing  in  pork. 
Beef  tapeworm  is  what  we  see  in  ninety-nine  cases  out 
of  one  hundred  at  the  Massachusetts  General  Hospi- 
tal. The  first  and  most  important  thing  to  be  said 
about  both  is  that  they  are  entirely  harmless,  so  far  as 
we  know,  and  produce  no  symptoms  whatsoever.  The 
patient  finds  out  his  disease  simply  by  discovering  the 
worm  in  discharges  from  the  bowels.  The  symptoms 
of  worms  is  one  of  the  subjects  on  which  the  laity  has 
clear  but  wholly  false  ideas,  —  the  idea,  for  instance, 
that  the  tapeworm  patient  has  a  ravenous  appetite  in 
order  to  support  himself  and  the  tapeworm,  and  the 
other  popular  belief  that  if  a  child  scratches  his  nose 
or  grinds  his  teeth  in  his  sleep,  he  must  have  worms. 
None  of  these  things  is  true.  There  is  a  popular 
aesthetic  prejudice  against  harboring  these  animals  in- 
definitely in  our  intestines,  and  there  is  no  reason  why 
we  should  not  be  rid  of  them,  since  they  are  very  easy 
to  cure.  As  a  rule  it  does  not  pay  to  try  to  cure  them 
at  home.  We  do  not  treat  them  as  out-patients  at  the 
Massachusetts  General  Hospital,  but  send  them  into 

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the  wards  for  forty-eight  hours,  within  which  time  we 
can  generally  rid  the  patient  of  his  worm.  We  give 
a  medicine  which  is  very  distasteful  to  the  worm, 
whereby  he  releases  his  hold  upon  the  intestine;  then 
we  give  a  purge  and  sweep  him  out. 

There  is  another  tapeworm,  the  fish  tapeworm,  never 
seen  here  except  when  imported,  usually  from  Norway 
or  the  Baltic  provinces  of  Russia.  This  worm  does 
produce  very  severe  symptoms,  sometimes  an  anemia 
of  the  severest  type,  which  if  not  checked  may  be  fatal. 
But  it  is  perfectly  easy  to  kill  this  worm  by  medicines 
given  by  mouth.  When  we  are  trying  to  swell  the  very 
small  list  of  diseases  which  we  can  cure,  we  always  put 
in  tapeworm  which  we  can  surely  cure  with  a  drug. 

Pinworms.  The  tapeworm  is  anywhere  from  ten  to 
twenty  feet  long,  The  pinworm  is  one  half  to  one  inch 
long,  a  minute,  threadlike  creature  which  settles  down 
in  the  lowest  segment  of  the  bowel  and  causes  itching 
with  local  irritation,  especially  in  children.  It  is  harm- 
less except  for  the  local  irritation,  and  can  easily  be 
expelled  by  the  application  of  astringent  solutions. 

Another  species,  the  round  worm,  is  about  six  inches 
long,  looking  like  a  large  earthworm,  also  perfectly 
harmless,  often  vomited  or  passed  by  foreigners,  espe- 
cially Italians.  It  causes  no  symptoms,  but  sometimes 
alarms  the  patient  and  attendants.  It  is  easily  expelled. 

The  only  worm  that  most  of  us  have  often  heard  of 
is  the  hookworm,  which  in  the  Southern  States  of  this 

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DISEASES  OF  THE   MUSCLES 

country  is  a  very  serious  scourge.  Up  to  1898,  when 
one  of  our  army  officers,  Dr.  Bailey  K.  Ashford,  dis- 
covered the  presence  of  hookworm  in  the  Spanish  pe- 
ons of  Cuba  and  Porto  Rico,  it  was  supposed  to  be  un- 
known in  the  Western  Hemisphere.  We  had  known  of 
it  only  in  Cornish  and  Swiss  miners.  Yet  there  is  every 
reason  to  suppose  that  it  has  always  been  here,  and 
when  the  American  Government  occupied  Porto  Rico, 
about  nine  tenths  of  the  whole  population  was  found 
to  be  affected  with  hookworm. 

Hookworm  causes  a  more  or  less  severe  anemia, 
sometimes  fatal,  usually  not  fatal  but  very  debilitating; 
hence  the  newspaper  tales  about  the  "lazy  bug."  It 
makes  people  unable  to  do  their  work.  My  brother  was 
impressed  in  Porto  Rico  by  visiting  a  town  before  and 
after  the  American  hookworm  brigade  had  organized 
a  camp  hospital  and  invited  the  whole  population  to 
come  and  be  treated  free.  He  was  there  before  and 
after  this  treatment,  and  those  who  employed  labor 
told  him  the  working  force  of  the  town  had  increased 
forty-five  per  cent  as  a  result  of  cleaning  the  hook- 
worms out  of  the  population. 

After  that  Dr.  Stiles,  of  the  United  States  Depart- 
ment of  Agriculture,  began  to  look  in  this  country  for 
similar  worms,  but  for  a  time  the  pride  and  stubborn- 
ness of  certain  people  made  it  very  hard  to  prove  the 
prevalence  of  hookworm  disease  in  our  Southern 
States.  At  the  present  time,  however,  it  is  generally 
admitted  and  widely  found,  but  is  being  rooted  out. 

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It  is  a  disease  which  has  no  possible  right  to  exist, 
for  we  can  both  prevent  it  and  cure  it.  We  can  prevent 
it  by  persuading  people  to  wear  shoes,  and  to  use 
privies.  We  can  cure  it  with  a  dose  of  thymol.  One  of 
the  most  bizarre  things  in  medicine  is  the  way  it  gets 
into  the  body.  It  is  an  intestinal  parasite,  yet  it  gets  in 
through  the  skin.  In  Southern  States  a  considerable 
part  of  the  population  walk  around  barefooted,  and 
get  what  they  call  "ground  itch,"  a  local  irritation 
especially  between  the  toes,  due  to  the  local  action  of 
the  hookworm  embryo  on  his  way  in.  He  gets  in 
through  the  skin  to  the  blood,  and  travels  all  the  way 
across  country  to  the  intestine  —  a  most  improbable 
story,  but  well  proved.  When  he  reaches  the  intestine 
he  stays  there,  and  gradually  poisons  the  body.  A  good 
many  people  get  so  used  to  it  that  they  do  not  have 
any  symptoms  and  do  not  become  anemic.  They  de- 
velop protective  substances  —  anti-toxins  —  within 
their  own  system.  But  not  everybody  is  so  fortunate. 

Q.  Is  hookworm  found  in  the  West  Indies? 

A.  I  have  no  doubt  that  it  is  common  through  all  the 
West  India  islands,  but  I  have  no  knowledge  of  it  outside 
of  the  United  States  and  its  dependencies.  It  is  common 
throughout  Egypt  and  in  a  good  many  hot  countries  else- 
where. 


CHAPTER  XIV 

INFECTIOUS   DISEASES 

I  THINK  it  is  important  for  laymen  to  know  that,  in  the 
temperate  zones  of  this  part  of  the  world,  —  that  is, 
outside  tropical  climates,  —  there  are  only  three  long, 
steady  fevers.  By  a  long,  steady  fever  I  mean  a  fever 
that  runs  more  than  two  weeks  without  touching  nor- 
mal. The  importance 'of  knowing  that  there  are  only 
three  is,  that,  as  a  rule,  if  we  can  narrow  it  down  to 
that,  it  is  possible  to  rule  out  two  and  be  sure  that  it  is 
the  third.  The  three  long,  steady  fevers  are  typhoid, 
tuberculosis,  and  sepsis  (generally  due  to  streptococ- 
cus). If  we  hear  of  any  one  who  has  a  long  fever 
not  called  any  one  of  those  three  things,  we  may  be 
quite  suspicious  of  the  diagnosis. 

Sepsis,  as  I  have  used  it,  is  a  wide  term  meaning 
blood  poisoning  from  any  form  of  suppuration,  such  as 
septic  hand,  foot,  wounds  of  any  sort,  from  appendici- 
tis or  deep  abscess,  as  of  the  liver,  or  from  inflamma- 
tion in  the  heart  itself  which  I  have  already  described 
• —  streptococcus  endocarditis.  In  relation  to  this  and 
all  other  fevers  I  have  already  said  that  social  workers 
and  all  other  educated  people  should  learn  how  to  use 
a  thermometer,  how  to  read  it,  clean  it,  and  shake  it 
down.  This  is  not  a  procedure  which  needs  a  long 
training  or  an  expert;  I  think  also,  for  the  same  reason, 

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social  workers  should  learn  to  feel  pulses,  to  know" 
where  the  pulse  is  and  be  able  to  count  it.  Sometimes 
it  is  very  reassuring  to  discover  that  a  person  whom  we 
think  very  sick  indeed   has   a  pulse  of  72  or  there- 
abouts —  a  normal  pulse. 

For  us  all  the  most  important  thing  about  typhoid 
fever  to-day  is  that  it  is  gradually  disappearing  from  the 
earth.  Even  within  the  twenty- four  years  that  I  have 
been  practising  medicine,  I  have  seen  a  marked  dimi- 
nution in  typhoid  fever.  Nowadays  there  is  hardly 
enough  to  teach  about ;  in  my  student  days  the  diffi- 
culty was  that  the  wards  were  full  of  typhoid.  We 
know  more  about  typhoid,  how  it  is  conveyed  and  how 
prevented,  than  almost  any  other  disease,  and  it  ought 
to  be  perfectly  possible  to  wipe  it  out.  The  more  civ- 
ilized and  carefully  policed  countries  have  wiped  it  out, 
and  it  is  a  pretty  good  index  of  the  backwardness  of 
any  community  if  it  has  a  high  typhoid  rate.  Drinking- 
water  and  milk  (we  cannot  have  impure  water  and 
yet  pure  milk,  since  the  containers  in  which  milk  is 
put  are  always  washed  with  water,  and  germs  therefore 
get  into  the  milk)  are  usually  the  causes  of  typhoid. 

In  Philadelphia  they  cut  the  mortality  of  typhoid 
to  about  one  third  what  it  was,  by  doing  nothing  in  the 
world  but  improving  their  water  supply.  In  and  about 
Boston  the  typhoid  mortality  has  gone  rapidly  down 
since  we  have  had  the  present  water  supply,  one  of  the 
best,  I  think,  in  any  community.  Milk  epidemics  are 
commoner  than  water  epidemics  in  recent  years.  A 

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INFECTIOUS   DISEASES 

milkman  or  some  one  of  his  employees  gets  typhoid, 
but  does  not  know  he  has  it,  and  continues  to  have  the 
bacilli  and  pass  them  out  in  the  urine  and  feces. 
Thence  it  is  possible  for  the  bacilli  to  get  into  the 
milk,  and  they  do.  Time  and  time  again  typhoid  has 
been  traced  to  an  unsuspected  typhoid  carrier  in  the 
family  of  a  milk-dealer.  We  use  this  word  carrier 
to  signify  any  person  who  is  carrying  around  bacilli 
and  can  infect  other  people,  though  not  himself  suffer- 
ing from  the  disease.  In  the  same  way  we  speak 
of  diphtheria  carriers.  A  great  deal  of  stress  has  been 
laid  upon  the  fly  as  a  possible  carrier  of  typhoid, 
and  no  one  can  possibly  deny  that  flies  sometimes  do 
carry  typhoid,  but  I  think  them  a  diminished  and 
pretty  nearly  finished  factor.  "Swatting  the  fly"  is 
excellent  exercise,  but  has  little  to  do  with  public 
health  except  in  that  way. 

Typhoid  fever  runs  a  course  of  about  four  weeks. 
We  have  more  definite  diagnostic  measures  for  it  than 
for  almost  any  other  disease,  and  we  should  be  sure  of 
our  diagnosis  in  practically  every  case.  We  can  get 
the  bacilli  out  of  the  patient's  blood,  or  we  can  do  other 
tests,  especially  the  test  called  "the  Widal,"  after  the 
Frenchman  who  described  it  in  1896.  It  is  possible  to 
make  this  diagnosis  without  seeing  the  patient,  and 
boards  of  health  often  do.  The  blood  is  sent  by  mail 
and  tested  in  the  state  or  city  laboratory.  In  doubtful 
cases,  then,  in  our  contact  with  fevers,  we  should  make 
sure  that  these  tests  are  made.  They  are  as  important 

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as  the  Wassermann  test  in  syphilis  or  the  sputum  ex- 
amination in  tuberculosis. 

Nine  people  out  of  ten  get  well.  The  mortality  is  ten 
per  cent  —  among  children  much  smaller,  as  it  is  in 
almost  all  diseases  which  both  children  and  adults 
have.  We  have  no  treatment  for  the  disease,  but  nurs- 
ing makes  a  big  difference.  We  have  no  medicine  that 
we  rely  upon  at  all,  but  in  a  long  fever  like  this  a  good 
nurse  can  do  much  by  feeding  a  patient  who  does  not 
want  to  take  food,  by  good  care  of  his  mouth,  by  bath- 
ing him  skilfully  and  frequently,  by  encouraging  him, 
and  by  keeping  the  bed  in  proper  condition  so  that 
bedsores  do  not  form.  That  may  make  a  difference,  I 
think,  between  life  and  death.  I  have  often  felt  when 
attending  difficult  cases  of  typhoid  that  the  right  kind 
of  a  nurse  had  saved  life. 

It  is  one  of  the  fevers  that  relapses,  and  after  the 
regular  four  weeks  it  may  go  on  and  last  two  or  three 
weeks  more,  or  even  longer.  I  have  known  it  to  last 
three  or  four  months,  with  relapse  after  relapse  and 
final  recovery.  We  do  not  know  the  cause  of  relapses 
nor  how  to  prevent  them.  We  used  to  consider  them 
due  to  indiscretions  in  diet,  but  nobody  believes  that 
to-day.  The  relapses  are  generally  much  milder  than 
the  original  attack. 

One  of  the  curious  things  about  typhoid  is  that  peo- 
ple are  sometimes  healthier  after  an  attack  than  before ; 
people  who  were  thin  are  especially  apt  to  be  stouter, 
not  merely  for  the  first  few  weeks,  but  for  life. 

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INFECTIOUS  DISEASES 

Typhoid  can  be  prevented  by  anti-typhoid  vaccina- 
tion. One  of  the  greatest  feats  of  all  time  I  think  in 
public  health  is  the  wiping-out  of  typhoid  fever  in  the 
United  States  Army,  where  anti-typhoid  vaccination 
is  now  compulsory.  Every  one  who  has  occasion  to 
travel  where  he  knows  nothing  about  the  water  supply, 
or  who  is  in  contact  with  typhoid  patients,  ought  to 
take  an ti- typhoid  vaccination.  There  is  no  danger  and 
no  considerable  discomfort,  and  it  is  a  very  real  pro- 
tection. We  had  typhoid  among  the  nurses  in  the 
Massachusetts  General  Hospital  practically  every  year 
until  we  had  them  all  vaccinated ;  since  then  there  has 
been  an  extraordinary  change  for  the  better.  Typhoid 
is  caught  in  the  nursing  of  patients  by  the  nurse's  get- 
ting the  bacilli  on  to  her  hands  and  from  the  hands 
into  the  mouth  and  so  into  the  blood  and  into  the 
intestine. 

Q.  How  long  does  vaccination  immunity  last? 

A.  That  question  cannot  yet  be  precisely  answered.  Few 
doctors  think  that  it  lasts  more  than  two  years ;  perhaps  not 
so  long. 

Diphtheria  is  a  disease  of  childhood,  and  mostly  of 
the  children  before  school  age.  School  nurses  do  a 
great  deal  to  prevent  diphtheria,  but  not  in  the  schools. 
It  is  the  school  nurse's  work  in  the  home  that  checks 
diphtheria;  she  gets  hold  of  it  early  and  gets  it  treated. 
It  is  one  of  the  most  contagious  of  diseases,  and  with 
present  treatment  it  carries  a  mortality  of  somewhere 
between  two  and  six  per  cent,  according  to  how  early 

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*the  disease  is  treated.  If  diagnosis  is  made  the  first 
day,  there  is  almost  no  mortality;  but  it  is  not  often 
made  before  the  third  or  fourth.  Our  most  successful 
serum  treatment  is  the  serum  treatment  of  diphtheria, 
and  it  is  one  of  the  eight  or  nine  diseases  which  we  can 
say  we  really  cure.  One  of  the  most  wonderful  things 
that  one  can  ever  see  in  medicine  is  the  clearing-up 
of  a  diphtheritic  child's  throat  without  a  touch  of  local 
treatment,  simply  from  the  injection  of  diphtheritic^ 
serum.  Early  treatment  is,  as  before  said,  the  great 
thing,  and  early  treatment  cannot  be  had  unless  throat 
cultures  are  easily  obtained  and  promptly  examined. 
The  throat  is  not  very  sore,  often  not  as  sore  as  in  or- 
dinary tonsillitis.  It  swells  from  the  start,  but  unless 
one  takes  cultures  of  a  great  many  suspected  throats 
one  would  miss  a  great  many  cases  of  diphtheria.  It 
takes  about  twelve  hours  —  perhaps  eight  at  the 
shortest  —  for  the  germs  to  develop  in  culture  so  that 
we  can  make  a  diagnosis  from  a  throat  culture.  The 
process  of  taking  a  culture  is.  simply  to  put  a  bit  of 
sterile  cotton  upon  a  stick  or  a  wire,  rub  it  against  the 
throat  where  it  is  suspected,  and  send  that  swab  in  a 
sterile  test-tube  to  the  laboratory  for  examination. 
The  reason  it  takes  time  is  that  the  bacilli  have  to 
grow  upon  a  culture  medium  before  there  are  enough 
of  them  to  be  recognized. 

Q.  Is  diphtheria  in  the  nose  and  ears  just  as  serious? 
A.  I  do  not  think  there  is  any  difference. 


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INFECTIOUS   DISEASES 

What  we  most  fear  in  diphtheria  is  that  it  will  get 
into  the  larynx  around  the  vocal  cords,  because  there 
it  so  easily  chokes  the  child.  If  it  gets  down  there  we 
keep  on  with  the  serum  treatment,  but  we  also  pass  a 
metal  tube  through  the  larynx  to  keep  it  open.  This  is 
called  "intubation,"  and  needs  a  knack  which  com- 
paratively few  physicians  have,  yet  it  often  saves  life. 

Within  the  last  few  years  we  have  become  aware  of 
certain  dangers  in  the  anti-toxin  treatment  of  diph- 
theria, which,  while  they  do  not  concern  many  people, 
are  serious  to  a  few  people.  If  a  person  is  hypersensi- 
tive to  the  proteid  secretions  of  a  horse,  —  for  instance, 
to  a  horse's  breath,  in  other  words,  if  he  has  any  horse 
asthma,  —  the  injection  of  immune  horse  serum,  which 
is  what  we  use  as  diphtheria  an ti- toxin,  may  produce 
very  severe  symptoms  which  are  often  fatal.  The 
most  terrible  results  are  in  people  who  have  not  got 
diphtheria,  but  are  given  serum  in  perfect  health  as  a 
protective,  and  die  of  it.  When  I  was  at  Johns  Hopkins 
a  few  years  ago  they  were  having  an  epidemic  in  the 
hospital.  The  house  physicians,  nurses  and  orderlies 
had  all  been  exposed,  and  were  in  a  very  considerable 
quandary  as  to  whether  they  should  receive  a  "  protec- 
tive" dose.  Most  of  them  chose  not  to,  because  they 
preferred  to  take  their  chance  of  being  given  the  serum 
after  they  got  the  diphtheria  (in  case  they  got  it), 
rather  than  take  the  chances  of  the  anaphylaxis. 
Anaphylaxis  is  the  result  of  hypersensitiveness  to  horse 
tissues.  If  a  person  of  that  type  gets  diphtheria,  or  is 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

exposed  to  it  and  takes  anti- toxin,  there  is  a  big  risk 
that  the  (horse)  serum  will  produce  serious,  even  fatal 
symptoms  which  we  call  "  anaphylactic  shock." 

There  is  a  test  recently  invented,  the  "Schick  test/1 
whereby  we  can  tell  who  is  naturally  immune  to  diph- 
theria. A  considerable  portion  of  all  humanity  are 
naturally  immune  to  diphtheria,  and  cannot  get  it. 
If  we  find  that  we  are  immune,  we  do  not  need  to  take 
anti-toxin  or  anything  else,  which  is  a  great  help  in 
fighting  the  trouble. 

Diphtheria  sometimes  leaves  paralysis  in  the  throat 
or  in  the  leg ;  both  are  usually  recovered  from  entirely ; 
it  is  a  temporary  neuritis  —  infectious  neuritis,  either 
of  the  throat  or  of  one  of  the  legs  —  which  carries  a 
perfectly  good  prognosis. 

Q.  Are  there  any  dangers  in  the  Schick  test? 
A.  None  whatever;  it  is  just  like  the  Von  Pirquet  for 
tuberculosis. 

Somewhere  about  three  per  cent  of  all  children  of 
school  age  carry  diphtheria  bacilli  in  their  throats. 
But  many  of  these  children  carry  a  bacillus  which,  al- 
though, as  I  have  said,  microscopically  indistinguish- 
able from  the  diphtheria  bacillus,  does  not  cause  the 
disease  in  animals,  "is  not  pathogenic"  as  the  doctors 
say.  We  suppose  that  it  is  a  weak  imitation  of  the  vir- 
ulent diphtheria  bacillus.  At  one  time  there  was  some 
hope  that  we  might  be  able  to  check  diphtheria  epi- 
demics by  getting  hold  of  all  the  "diphtheria  carriers. " 

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INFECTIOUS  DISEASES 

If,  for  example,  at  the  end  of  the  summer,  we  could 
round  up  all  the  school-children  and  shut  up  all  the  car- 
riers when  school  began,  theoretically  there  should  be 
no  diphtheria.  Diphtheria  slacks  off  very  much  when 
the  children  are  not  in  school,  and  begins  to  flour- 
ish again  progressively  worse  after  they  get  together. 
That  idea  was  tried  out  here  in  Boston  in  the  Brighton 
Ward.  I  induced  the  Board  of  Health  to  get  together 
all  the  Brighton  children  who  were  to  be  in  school  in  a 
given  year,  to  take  cultures  from  their  throats,  and 
then  to  keep  the  carriers  at  home.  They  took  the  cul- 
tures and  they  kept  some  of  the  carriers  at  home,  — 
not  very  many,  —  but  the  striking  thing  was  that 
when  diphtheria  sprang  up  in  the  schools  in  its  regular 
way,  it  did  not  spring  up  in  the  families  of  the  known 
carriers.  In  other  words,  the  disease  did  not  spread, 
so  far  as  we  can  see,  through  carriers.  That  ingenious 
procedure  was  based  upon  a  false  hope,  and  to-day  we 
do  not  know  any  way  of  stopping  diphtheria  epidemics, 
except  to  isolate  the  children  or  the  family  in  which 
the  disease  itself,  not  merely  the  carrier,  is  known  to 
exist. 

Scarlet  fever,  measles,  and  chicken-pox  are  generally 
classed  together  under  the  heading  of  "the  exanthe- 
mata" meaning  those  which  break  out  with  a  rash  on 
the  skin. 

We  do  not  know  much  about  the  organism  of  scarlet 
fever  or  of  any  of  the  exanthemata;  we  have  been 

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searching  for  many  years  for  these  germs,  but  despite 
the  recent  discovery  of  Dr.  F.  B.  Mallory  we  know 
little  about  them.  This  ignorance  makes  the  diagnosis 
and  the  treatment  of  the  exanthemata  still  wholly 
unsatisfactory.  The  diagnosis  of  scarlet  fever  is  still 
based  chiefly  on  the  presence  of  a  sore  throat  and  a 
red  rash.  But  there  are  many  other  things  that  give 
a  red  rash  indistinguishable  from  the  rash  of  scarlet 
fever.  Consequently  there  are  many  wrong  diagnoses, 
and  always  will  be  until  we  have  some  better  way  of 
recognizing  the  disease.  At  present,  when  a  child  has 
a  sore  throat  and  develops  a  red  rash  with  fever,  we 
suspect  scarlet  fever,  but  we  often  suspect  it  wrongly. 
Especially  in  young  children  there  are  a  great  many 
sudden  red  rashes,  after  tonsillectomy  for  example.  In 
such  cases  scarlet  fever  is  often  suspected  and  nobody 
can  positively  say  whether  it  is  or  is  not  present.  I 
should  not  advise  any  layman  to  try  to  make  this  di- 
agnosis. There  are  very  few  physicians  who  are  in  any 
way  certain  about  it,  and  they  are  often  wrong.  The 
throat  and  the  fever  and  the  rash  are  about  as  much 
as  we  have  to  go  on.  The  rash  after  a  little  while  be- 
comes a  continuous  red  blush,  not  spotted  like  measles. 
In  the  early  stages  we  can  see  bits  of  normal  skin  be- 
tween the  red  marks,  but  as  the  disease  goes  on  the 
rash  fades  at  its  edges  into  its  neighboring  portions,  so 
that  it  makes  a  pretty  continuous  red  blush.  Quite 
often  the  diagnosis  remains  uncertain  until  the  child 
begins  to  peel.  I  have  often  heard  disputes  between 

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INFECTIOUS  DISEASES 

physicians  in  which  the  closing  argument  was,  "Well, 
I'll  bet  you  he  will  peel."  Peeling  makes  us  about  as 
certain  of  a  diagnosis  as  we  can  be,  but  peeling  comes 
when  the  active  stages  of  the  fever  are  past,  and  hence 
when  diagnosis  and  isolation  are  not  important. 

There  are  two  points  of  importance.  First,  that 
modern  health  physicians  do  not  any  longer  disinfect 
houses,  bedclothes,  etc.,  after  scarlet  fever  or  after 
diphtheria,  or  after  any  of  the  germ  diseases.  That  has 
been  the  theory  and  the  belief  of  the  Boston  Board  of 
Health  for  years,  but  it  is  only  within  a  year  that  they 
have  actually  stopped  disinfecting.  I  am  not  quite 
sure  that  they  have  stopped  it  after  all  the  infectious 
diseases  even  now.  The  familiar  process  of  burning 
formaldehyde,  and  making  everything  smell  as  badly 
as  we  can,  has  now  been  abandoned  wherever  science 
reigns  —  not  everywhere  because  a  good  many  boards 
of  health  are  afraid  of  what  people  will  say ;  but  there  is 
really  no  disagreement  among  competent  physicians 
on  this  subject  any  more.  Disinfecting  is  of  no  use.  A 
good  many  health  officers  remain  in  the  halfway  stage, 
saying  to  the  family,  "  You  must  make  a  very  active 
use  of  soap  and  water  after  a  case  of  infectious  disease." 
But  no  physician,  I  think,  supposes  that  this  has  any- 
thing to  do  with  infection  or  prevents  infection  in 
future.  It  is  always  a  good  thing  to  clean  house,  and 
so  if  we  can  get  people  to  clean  house,  we  do.  The  be- 
lief at  the  present  time  is  that  by  the  time  the  germ 
has  died  out  in  the  sick  person,  it  has  long  before  died 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

out  in  his  surroundings.  Hence  his  clothes  or  his  books 
or  his  furniture  do  not  give  the  disease  to  anybody  else. 
We  all  of  us  remember  most  detailed,  circumstantial 
evidence  about  cases  in  which  the  disease  has  been 
passed  along  by  clothes  or  books,  but  these  are  not 
believed  to-day.  The  evidence  is  all  the  other  way. 

The  other  important  thing  about  the  exanthemata, 
which  is  also  rather  hard  to  get  people  to  believe,  is 
that  the  most  contagious  time  is  the  earliest  period  of 
the  disease,  and  not  the  latest.  We  were  all  of  us 
brought  up  to  believe  that  the  time  people  were  peeling 
was  the  most  dangerous  of  all  times ;  but  the  present 
belief  is  that  it  is  the  least  dangerous.  The  beginning 
of  the  disease,  when  there  is  a  sore  throat,  is  the  time 
when  contagion  is  the  most  likely  to  take  place.  Of 
course  none  of  those  questions  can  be  settled  in  a  way 
to  satisfy  everybody  until  we  know  more  about  the 
germ  and  can  say  that  it  is  or  is  not  in  a  given  place. 

We  have  no  treatment  of  scarlet  fever.  The  work  of 
the  physician  is  simply  to  see  that  isolation  is  carried 
out  and  that  complications  of  the  disease,  such  as  kid- 
ney trouble  or  ear  trouble  or  heart  trouble,  are  treated. 
For  the  uncomplicated  disease  we  have  absolutely  no 
treatment,  and  it  is  not  at  all  likely  that  we  shall  have 
until  we  know  more  about  the  germ  and  can  make 
some  sort  of  serum  or  anti-body  to  combat  it. 

I  just  mentioned  the  three  commonest  complica- 
tions, nephritis  (Bright's  disease),  middle  ear  trouble, 
and  heart  disease.  If  nephritis  occurs,  the  physician 

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INFECTIOUS  DISEASES 

must  see  that  the  proper  diet  —  milk  diet  in  the  early 
stages  —  is  given.  If  the  ear  is  affected  he  must  see 
that  proper  treatment  is  given  by  a  specialist,  and  if 
the  heart  is  affected  he  must  see  that  the  child  is  kept 
quiet  for  a  long  time,  as  advised  in  other  types  of 
acute  heart  trouble. 

Measles  is  a  little  easier  to  diagnose,  less  often  mis- 
taken for  other  things.  There  are  many  things  that 
cause  a  red  rash  like  scarlet  fever.  There  are  not  many 
things  that  cause  the  spotted,  pimply  rash  of  measles, 
with  running  from  the  eyes  and  nose  and  a  fever.  That 
combination  is  generally  recognizable  by  the  trained 
layman  as  well  as  by  the  physician.  The  doctor  can 
use  no  instruments  of  precision  whatever  here;  he 
can  just  look  at  the  patient  and  at  the  temperature 
chart,  and  make  sure  by  cross-questioning  that  the 
patient  has  taken  no  bromide,  iodide,  or  other  drug 
that  can  produce  such  a  rash.  The  most  impor- 
tant thing  about  measles  is  that  tuberculosis  of  the 
lungs  often  follows  it,  and  that  acute  broncho-pneu- 
monia sometimes  complicates  it  and  kills.  We  used  to 
think  that  "  children's  diseases "  were  ailments  that 
children  had  better  have  and  get  through  with.  That 
is  not  the  prevailing  belief  at  all  to-day,  because  in  the 
first  place  so  many  children  die  of  them,  and  in  the 
second  place  they  may  leave  lifelong  wounds  upon  the 
organs  of  the  body.  Measles  predisposes  to  tubercu- 
losis, presumably  because  it  weakens  the  resistance  of 

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the  child  at  a  time  when  he  is  very  susceptible  to  infec- 
tion of  any  kind,  and  because  tuberculosis  is  one  of  the 
commonest  kinds  of  infection  that  is  always  in  the 
child's  immediate  vicinity.  We  have  no  reason  to  sup- 
pose that  the  germs  of  measles  and  tuberculosis  have 
anything  to  do  with  each  other,  but  we  know  that  all 
children  are  tremendously  susceptible  to  tuberculosis, 
and  that  almost  every  child  in  a  large  city  has  had  it 
before  he  is  ten.  Hence  in  his  weakness  after  measles 
he  is  more  likely  to  catch  tuberculosis  than  anything 
else  that  is  going. 

Chicken-pox,  whose  scientific  name  is  varicella,  is 
worth  spending  a  word  or  two  on  in  relation  to  termi- 
nology. There  is  the  smallpox  and  the  large  pox  and  the 
chicken-pox.  The  original  spelling  was  "pocks,"  a  pock 
or  many  pocks.  The  "pock-marked"  person  had,  of 
course,  the  right  spelling.  Smallpox  is  the  disease 
which  gives  small  marks ;  the  large  pox  is  syphilis,  and 
is  still  referred  to  vulgarly  as  "the  pox."  Chicken-pox 
gives  the  smallest  pocks  of  all,  sometimes  none  at  all; 
that  is,  the  scars  left  after  it  are  the  smallest.  Vari- 
cella is  the  mildest  and  the  least  important  of  all  the 
children's  diseases,  practically  never  having  any  im- 
portant complications  or  results.  It  sometimes  looks 
very  much  like  smallpox,  and  in  times  of  an  epidemic 
of  smallpox  very  serious  mistakes  sometimes  happen. 

This  diagnosis  is  a  matter  for  experts.  There  are 
few  men,  even  among  trained  physicians,  who  consider 

358 


INFECTIOUS  DISEASES 

themselves  expert  on  the  difference  between  smallpox 
and  chicken-pox,  because  the  average  physician  does 
not  see  enough  smallpox.  In  general  the  distinction  is 
that  the  person  is  not  sick  enough  with  chicken-pox; 
he  is  not  prostrated ;  there  is  no  evidence  of  being  very 
ill.  Then  chicken-pox  gets  through  its  course  very 
much  quicker.  I  remember  being  called  once  to  a  chil- 
dren's institution  in  Boston  where  there  were  about 
two  hundred  children,  and  one  of  them  had  a  disease 
which  was  either  chicken-pox  or  smallpox;  the  child 
had  already  exposed  a  good  many  others.  Should  the 
children  all  be  quarantined  or  sent  home?  The  child 
had  been  sick  four  days;  some  of  the  "pocks"  were 
already  healing  up,  and  that  was  really  all  the  evidence 
that  was  needed.  Smallpox  is  never  healing  in  four 
days,  so  that  this  particular  decision  was  easy  to  make. 
As  with  scarlet  fever,  so  with  measles  and  chicken- 
pox,  we  have  no  treatment;  we  do  nothing  but  pro- 
tect the  other  members  of  the  family  from  infection. 
Note  that  in  all  the  diseases  spoken  of  thus  far  I  have 
taken  pains  to  say  when  there  is  and  is  not  a  treatment. 
I  think  this  is  important  when  one  tries  to  calculate 
what  the  cost  of  an  illness  ought  to  be.  The  cost  of  an 
illness  in  which  there  is  no  treatment  ought  to  be  con- 
siderably less  than  one  which  requires  a  physician  and 
a  nurse  in  constant  attendance. 

Whooping-cough,  or  pertussis,  is  the  only  one  of  this 
group  whose  cause  we  know.  The  bacillus  of  whooping- 

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cough  is  recognized,  and  that  gives  us  some  reasonable 
hope  that  some  day  we  may  have  a  cure ;  but  so  far  we 
have  not  any.  Whooping-cough  is  diagnosed  by  the  na- 
ture of  the  cough,  by  the  blood  examination,  and  by 
the  looks  of  the  child  during  paroxysms.  There  is  very 
little  science  in  it.  Any  one  who  has  seen  a  few  cases 
can  make  the  diagnosis.  Once  heard,  the  crowing 
inspiration  which  follows  the  series  of  coughs  will  be 
recognized  very  clearly  whenever  we  hear  it  again. 
Among  other  things,  the  way  the  child  coughs  and 
coughs  and  coughs  until  he  is  blue  in  the  face,  and  then 
often  vomits  and  is  relieved,  are  very  characteristic. 

Whooping-cough,  like  the  other  diseases  just  men- 
tioned, —  especially  like  measles,  —  leads  to  broncho- 
pneumonia  and  to  tuberculosis,  and  through  these  two 
leads  to  a  great  many  deaths.  That  has  only  been  real- 
ized, I  think,  of  late  years,  and  as  yet  there  is  no  provi- 
sion whatever  in  the  city  of  Boston  for  the  isolation  of 
whooping-cough.  Sooner  or  later  it  will  have  to  be 
recognized  as  a  disease  from  which  the  public  needs 
protection  as  much  as  from  some  of  those  which  are 
now  isolated. 

Whooping-cough  has  no  fixed  length  or  course  as  the 
exanthemata  do.  The  worst  of  scarlet  fever,  measles,  or 
chicken-pox  is  over  in  ten  days;  whooping-cough  may 
run  for  months  and  has  no  ordinary  or  average  period. 
Perhaps  we  can  say  that  six  weeks  is  somewhere  near 
its  average  duration,  but  it  may  run  for  a  much  longer 

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INFECTIOUS  DISEASES 

period.  Sometimes  children  won't  get  any  better  until 
they  are  taken  to  the  seashore  or  the  mountains. 

Gonorrhea.  The  gonococcus,  the  organism  of  this 
disease,  has  certain  favorite  spots  of  infection  in  the 
body.  We  cannot  say  why  it  is  that,  after  infecting  the 
urethra,  where  it  usually  starts,  it  should  jump,  for 
instance,  to  the  joints.  Other  favorite  sites  for  gonor- 
rhea, besides  those  that  I  have  just  mentioned,  are  the 
bladder,  the  Fallopian  tubes,  the  epididymis  and  the 
prostate  gland.  To  a  certain  extent  it  affects  all  the 
parts  in  the  vicinity  of  those  that  I  have  mentioned 
— the  vagina  and  uterus,  sometimes  the  peritoneal  cav- 
ity. It  produces  pus,  acute  inflammation,  and  after 
that  scar  tissue,  with  the  result  of  closing  various  pas- 
sages which  ought  to  remain  open ;  first  of  all  the  ure- 
thra, with  resulting  ''stricture,"  which  makes  difficult 
the  passage  of  urine  and  leads  to  all  sorts  of  painful  and 
disabling  results.  It  closes  the  Fallopian  tube  in  wo- 
men, causing  sterility,  and  the  corresponding  tube  in 
the  male,  the  tube  leading  from  the  testicle  to  the  ure- 
thra, so  that  one  or  both  sexes  may  be  rendered  ster- 
ile in  this  way. 

The  gonorrheal  vaginitis  of  little  girls  has  already 
been  referred  to  (see  page  1 96) .  The  disease  is  extraor- 
dinarily stubborn  and  difficult  to  treat.  Some  say  it 
is  hopeless,  but  those  who  have  worked  hardest  with 
it  believe  that  they  can  stop  it,  or,  at  any  rate,  shorten 
its  course ;  but  they  will  add  that  it  is  hardly  worth 

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while  unless  we  can  dig  out  the  source  of  infection. 
Otherwise  the  child  is  perfectly  sure  to  be  reinfected. 
To  find  and  check  the  source  of  infection  involves  get- 
ting on  terms  with  the  family  which  are  delicate  and 
difficult,  but,  for  the  tactful,  not  impossible.  The  pres- 
ent belief  is  that  the  return  of  the  disease,  which  is 
seen  in  almost  every  case,  is  in  fact  a  reinfection  and 
not  a  relapse  of  the  original  infection.  It  seems  to  me 
a  matter  on  which  social  workers  especially  need  to  be 
well  informed.  The  treatment  is  a  very  time-consum- 
ing, bothersome  process,  and  it  is  not  in  the  least 
worth  while  to  carry  it  out  unless  we  are  persuaded 
that  we  have  found  the  source  and  can  stop  it,  for 
otherwise  the  child's  trouble  is  sure  to  recur. 

This  vulvo-vaginitis  of  little  girls  has  been  recog- 
nized for  many  years,  and  treated  as  of  no  importance. 
That  it  is  gonorrheal  has  only  been  known  for  a  very 
few  years,  and  there  are  considerable  portions  of  the 
country  where  it  is  not  known  yet.  Because  gonorrhea 
was  always  associated  in  people's  minds  with  a  sexual 
fault,  and  because  it  is  perfectly  sure  that  in  little  girls 
it  may  arise  without  any  fault,  its  gonorrheal  origin 
was  not  suspected  at  all  until  recent  years. 

Of  gonorrhea  of  the  eyes  there  is  little  to  be  said.  A 
great  deal  of  attention  has  been  focused  upon  it  of  late 
years.  Until  very  recent  years  very  few  believed  that 
there  was  any  possibility  of  managing  gonorrhea  as  a 
family  problem.  No  one  thought  it  conceivable  that 
when  a  married  man  with  gonorrhea  entered  the  hos- 

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pital  anything  could  be  done  to  protect  the  members  of 
his  family;  or  vice  versa,  to  protect  the  husband  of  a 
married  woman  with  gonorrhea.  I  feel  sure  that  we  are 
going  to  make  progress  in  that  problem  as  soon  as  social 
workers  of  the  right  type  are  installed  in  the  clinics  for 
venereal  disease.  We  have  assumed  that  the  matter 
could  not  be  talked  out  with  members  of  a  family,  and 
that  no  one  could  possibly  do  anything  toward  pre- 
venting the  spread  of  disease  without  driving  patients 
to  stay  away  from  the  clinic  for  fear  of  publicity.  But 
although  we  have  attempted  in  the  Massachusetts 
General  Hospital  to  attack  this  problem,  certainly 
with  some  success,  we  have  no  evidence  whatever  that 
it  has  diminished  the  size  of  our  gonorrhea  clinic  or 
kept  anybody  away.  People  are  very  much  more 
ready  to  respond  to  an  appeal  against  infecting  others 
than  they  have  been  supposed  to  be.  Those  who  prac- 
tise genito-urinary  surgery  as  a  specialty  now  tell  us 
that  of  late  there  is  an  increase  in  the  number  of  young 
men  who  come  to  them  for  examination  before  mar- 
riage, fearing  that  they  may  not  have  been  cured  of  a 
gonorrhea  which  they  know  well  enough  they  have 
had  years  before.  The  train  of  events  which  leads  to  so 
many  evils  in  marriage  is  this:  The  young  man  gets 
gonorrhea,  thinks  he  is  cured,  thinks  he  is  safe  in 
marrying,  marries;  his  gonorrhea  wakes  up  again;  he 
infects  his  wife.  Knowing  that  train  of  events,  an  in- 
creasing number  of  young  men,  who  have  not  force  of 
character  enough  to  avoid  the  original  infection,  but 

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have  force  of  character  enough  to  hate  infecting  any 
one  else,  now  consult  a  specialist  before  marrying. 

We  have  a  test,  parallel  to  the  Wassermann  test,  a 
blood  test  for  gonococcus  infection.  This  is  a  very  use- 
ful thing,  supplementing  other  methods  of  discovering 
the  presence  or  absence  of  gonorrhea.  With  a  doubtful 
arthritis  the  blood  test  is  often  the  deciding  factor  in 
our  diagnosis,  prognosis,  and  treatment. 

The  question  is  very  often  asked,  and  quite  often 
answered,  "How  prevalent  are  gonococcus  infec- 
tions?" I  have  made  some  attempt  to  answer  that 
among  the  patients  who  come  to  the  Massachusetts 
General  Hospital  and  are  admitted  to  the  wards.1 
Confining  myself  to  men  over  sixteen,  practically  the 
only  ages  at  which  we  have  them  in  the  medical  wards 
of  the  Massachusetts  General  Hospital,  I  have  read 
through  a  very  large  number  of  volumes  of  our  records. 
Every  single  individual  is  asked  the  question,  has  he 
had  gonorrhea  or  has  he  not.  I  believe  the  answers  to 
this  question  are  given  truthfully,  not  because  I  think 
the  patients  are  always  truthful,  but  because  I  think 
under  the  particular  conditions  they  do  not  lie.  In  the 
first  place,  they  have  no  particular  sense  of  shame  in 
acknowledging  a  past  gonorrhea  to  a  doctor.  In  the 
second  place,  they  are  afraid  not  to  do  so,  because  they 
think  it  may  make  some  difference  to  their  present  ill- 

1  "Observations  regarding  the  Relative  Frequency  of  the  Different 
Diseases  Prevalent  in  Boston  and  its  Vicinity."  Delivered  at  the  Annual 
Meeting  of  the  Massachusetts  Medical  Society,  1911. 

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INFECTIOUS  DISEASES 

ness  in  case  they  lie.  As  the  result  of  that  inquiry,  in 
a  very  large  number  of  cases,  the  figures  show  that 
thirty-three  per  cent  of  the  class  of  men  admitted  to 
the  hospital  as  ward  patients  were  aware  that  they  had 
had  gonorrhea. 

I  believe  those  statistics  are  as  reliable  as  any  that 
we  can  get.  Very  much  higher  figures  have  often  been 
quoted,  but  not  usually  upon  any  particular  statistical 
evidence,  usually  from  some  one's  impressions,  or  from 
army  records,  which  is  certainly  not  a  fair  test.  There 
are  no  very  differing  conditions  in  races,  the  chief  being 
that  the  Jewish  people  have  apparently  but  one  third 
as  much  gonorrhea  as  the  rest.  There  is  no  considerable 
difference  between  Americans,  Irish  and  Italians;  all 
of  them  have  about  three  times  as  much  gonorrhea  as 
the  Jews.  This  investigation  was  made  five  years  ago. 
The  same  is  true  of  syphilis,  or  was  at  the  time  I  made 
this  investigation. 

Syphilis  is  about  one  third  as  common  as  gonorrhea 
according  to  the  confessions  and  knowledge  of  the  same 
group  of  people  just  referred  to.  But  this  does  not  rep- 
resent the  facts,  for,  although  I  believe  those  were  true 
answers,  it  is  much  more  possible  to  have  syphilis  and 
not  know  it  than  to  have  gonorrhea  unknowingly.  It 
is  perfectly  well  established  that  syphilis  is  often  ac- 
quired without  a  person  having  the  least  idea  of  it,  and 
shows  itself  in  something  like  tabes  or  aneurism  years 
after.  But  so  far  as  the  individual's  knowledge  is  con- 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

cerned,  it  occurs  in  about  ten  per  cent  of  the  hospital 
population  (males  over  sixteen)  in  this  part  of  the 
country.  About  twenty-five  per  cent  of  hospital  pa- 
tients show  a  positive  Wassermann  reaction. 

There  is  no  need  to  go  into  any  details  about  the 
germ  of  syphilis,  the  spirochaete.  It  has  only  been  rec- 
ognized of  late  years,  but  has  helped  us  very  much 
in  the  recognition  and  treatment  of  the  disease. 

We  divide  syphilis  into  congenital  and  acquired. 

Congenital  syphilis.  Aside  from  Wassermann's  re- 
action, most  of  the  points  which  the  physician  relies 
upon  in  recognizing  congenital  syphilis  are  points 
which  are  perfectly  obvious  to  the  unaided  eye.  I 
think  social  workers  ought  to  become  familiar  with 
them  because  the  disease  is  so  often  overlooked  and 
left  untreated  and  because  treatment  is  of  value  and 
should  be  instituted  at  once. 

(1)  First,  as  a  rule,  is  the  fact  that  the  baby  cannot 
easily  nurse  because  his  nose  is  filled  up ;  it  has  snuf- 
fles, so  that  it  cannot  get  its  breath.  Snuffles  at  a  time 
when  the  baby  is  too  young  to  have  a  cold  in  his  head, 
snuffles  in  a  newborn  baby,  is  very  suspicious.    It  is 
not  proof,  of  course. 

(2)  Not  long  after  that  is  noticed,  an  eruption  ap- 
pears upon  the  palms  of  the  hands  and  soles  of  the  feet. 
In  adults  this  is  not  so  characteristic,  but  there  are 
very  few  things  that  give  this  eruption  in  a  young  baby 
except  syphilis.  One  of  the  exceptions  is  the  drying  of 
the  tissues  that  comes  from  diarrhea.  A  baby  who  has 

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INFECTIOUS  DISEASES 

had  diarrhea  may  have  its  tissues  so  dried  that  there  is 
scaling  on  the  palms  and  soles  as  well  as  elsewhere.  If 
we  can  exclude  that,  a  scaling  eruption  on  the  palms 
and  soles,  or  an  eruption  there  without  scaling,  is  al- 
most characteristic  of  syphilis. 

(3)  The  corners  of  the  mouth  are  the  third  place  that 
we  look  at.  The  baby  gets  a  sore  at  the  corners  of  the 
mouth,  one  or  both,  which  in  healing  leaves  little  white 
scars  as  thick  as  the  mark  that  you  make  with  a  pencil, 
and  radiating  from  the  corner  of  the  mouth.  Other  dis- 
eases may  produce  the  same  thing;  it  is  not  in  itself 
proof  of  syphilis;  but  it  is  enough  to  make  us  sus- 
picious. 

(4)  Somewhat  later  come  the  changes  in  the  eyes, 
of  which  the  one  easiest  to  recognize  is  the  keratitis, 
whereby  the  bright  front  surface  of  the  eye  gets  a 
steamy,  slightly  opaque  look;  the  front  of  the  eye  is 
not  perfectly  bright  and  shiny  as  it  should  be.   After 
we  have  seen  this  once  or  twice  we  recognize  it  very 
quickly.   . 

(5)  Then  the  teeth;  here  we  have  to  repeat  what  I 
have  said  already,  that  nothing  is  absolutely  charac- 
teristic. The  only  teeth  that  we  are  concerned  with  are 
the  upper  front  incisors,  the  two  teeth  in  the  middle  of 
the  upper  jaw.    The  change  in  the  shape  of  the  teeth 
has  been  already  described  and  pictured.   One  of  the 
mistakes  that  I  have  seen  physicians  make  is  to  suspect 
syphilis  in  some  one  who  has  notched  teeth.  Half  the 
people  in  the  world  have  notched  teeth. 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

(6)  The  fingers  of  young  children  with  congenital 
syphilis  often  show  swellings  at  a  time  when  there  is 
very  little  else  except  syphilis  to  produce  such  swellings 
of  the  last  joint  or  the  one  before  the  last.  The  inflam- 
mation lasts  for  weeks,  and  is  important,  just  because 
the  children  are  so  young  and  because  tuberculosis  is 
about  the  only  other  disease  which  produces  such  swell- 
ings in  the  fingers  of  the  young  child. 

(7)  Then  the  shins.   The  sabre  shin  is  thickened  and 
often  curves  forward;  of  course  we  must  remember 
that  rickets  also  gives  a  curved  shin,  but  rickets  does  not 
enlarge  the  shin  bone  at  all ;  syphilis  does.  If  we  have 
any  other  child  at  hand  to  use  as  a  comparison,  and 
can  show  that  the  shin  bone  is  not  only  curved,  but 
thicker  than  normal,  we  have  important  evidence  of 
syphilis.   X-ray  of  the  shins  adds  conclusive  evidence. 

(8)  The  ears  are  less  often  affected,  I  think,  than 
most  of  the  other  parts  that  I  have  mentioned,  but  a 
middle-ear  trouble  does  come  from  syphilis  in  a  young 
child,  as  well  as  the  later  syphilitic  ear  troubles  which 
come  about  adolescence  and  are  more  common. 

Probably  until  recently  the  vast  majority  of  babies 
with  congenital  syphilis  have  died  early,  so  that  we  do 
not  know  much  about  this  form  of  syphilis  in  adults. 
But  the  outcome  of  congenital  syphilis  under  modern 
treatment  may  be  so  soon  changed  that  what  has  been 
said  may  not  be  true  ten  years  hence.  Even  without 
treatment  we  occasionally  see  young  adults  who  show 
evidence  of  having  had  syphilis  from  birth.  But  that 

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INFECTIOUS  DISEASES 

is  rare.  The  number  of  cases  past  twenty  that  most 
physicians  have  seen  is  probably  one  or  two  in  a  life- 
time. There  is  rather  a  characteristic  look  to  the  head 
in  the  few  who  do  grow  up  to  adolescence  or  adult  life. 
We  can  generally  distinguish  them  because  the  fore- 
head is  so  big  and  the  face  so  small,  and  as  we  look 
closely  we  can  generally  see  some  of  the  other  points, 
at  the  corners  of  the  mouth  or  in  the  teeth. 

The  disease  may  make  a  baby  look  like  a  little  old 
man;  one  of  the  pathetic  things  in  badly  nourished 
children  is  that  look  of  age,  and  syphilis  is  one  of  the 
diseases,  but  not  the  only  one,  that  makes  a  child 
look  so. 

Acquired  syphilis  is  generally  divided  into  four 
groups  of  symptoms,  though  we  recognize  that  they 
fade  into  each  other  on  their  edges :  primary,  second- 
ary, tertiary,  and  the  post-syphilitic  lesions  or  para- 
syphilitic  lesions  (which  are  of  the  nervous  system). 

The  primary  lesion  is  called  the  chancre.  Wherever 
the  bacillus  first  takes  root  we  get  a  sore  which  is  slow, 
—  lasts  weeks,  —  is  extraordinarily  free  from  pain 
considering  how  angry  it  looks,  and  has  a  great  deal 
more  hardness  or  induration  around  its  edge  than  most 
long-standing  sores  have.  As  one  sees  it,  for  instance, 
on  the  finger  or  on  the  lip  in  an  innocent  infection,  one 
notices  that  the  patient  complains  of  much  less  pain 
than  we  should  expect,  and  that  when  we  take  hold  of 
the  sore,  it  is  tough  and  grisly  around  the  edges.  But 
the  diagnosis  here  and  everywhere  in  syphilis  is  made 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

certain   only   by   microscopic  examination   and   the 
Wassermann  test. 

There  are  two  methods  of  microscopic  examination, 
the  examination  of  the  stained  smear,  something  like 
the  specimens  of  sputa,  and  the  examination  by  the 
dark-field  microscope  without  stain.  In  the  first  case  a 
little  of  the  watery  secretion  of  the  sore  is  stained  and 
put  upon  a  piece  of  glass  under  the  microscope,  where 
the  characteristic  shape  of  the  organism  of  syphilis,  a 
very  fine  snaky  cork-screw,  is  recognizable.  With  the 
dark-field  microscope  one  uses  no  stain,  but  sees  the 
motion  of  the  live  organism  against  the  black  field. 

I  think  it  is  important  for  social  workers  to  know  all 
these  facts,  because  they  often  are  in  the  way  of  getting 
people  to  the  point  of  being  certain  of  a  diagnosis,  and 
I  do  not  know  of  any  diagnosis  more  important  to  be 
certain  of,  because  of  the  danger  to  others  and  because 
of  the  long,  expensive,  but  most  valuable  treatment. 
The  Wassermann  test  is  our  other  great  method  of 
diagnosis. 

Somewhere  in  the  neighborhood  of  six  weeks  after 
the  first  infection  with  syphilis  (but  with  a  good  deal  of 
time- variation  in  individual  cases)  come  the  "second- 
ary" symptoms,  which  consist,  in  the  first  place,  of  a 
rash  on  the  body,  and  in  the  mouth.  More  than  that  it 
is  not  safe  to  say.  The  variety  of  these  rashes  which 
can  be  seen  is  simply  without  end.  Syphilis  can  imitate 
any  kind  of  skin  disease,  and  it  is  not  worth  while  even 
to  try  to  recognize  it.  No  layman  ought  to  attempt  it. 

370 


INFECTIOUS  DISEASES 

The  rash  inside  the  mouth  causes  what  are  called 
miicous  patches  —  white,  as  big  as  a  finger  nail,  pain- 
less, looking  a  little  like  a  canker  sore,  only  bigger, 
whiter,  and  lasting  far  longer.  The  individual  canker 
sore  lasts  only  a  few  days,  whereas  the  mucous  patch 
of  syphilis  always  lasts  for  weeks.  Moreover,  the 
mucous  patch  is  painless,  while  the  canker  sore  is  al- 
ways painful.  Mucous  patches  may  occur  anywhere  in 
the  mouth,  especially  along  the  inside  of  the  cheek;  but 
anywhere  else  also. 

At  the  time  of  this  eruption  the  individual  begins  to 
feel  sick;  he  has  not  felt  sick  heretofore.  He  begins  to 
have  a  little  fever  and  may  have  to  give  up  his  work, 
but  many  of  them  do  not  give  up  work,  and  it  is  those 
who  are  the  most  dangerous.  Those  who  have  moist 
eruptions  upon  the  skin  and  in  the  mouth  in  this  stage 
of  syphilis  are  the  most  dangerous  because  it  is  the 
most  contagious  of  all  types  of  syphilis.  With  this 
eruption  very  often  comes  a  sore  throat,  and  a  head- 
ache which  may  be  worse  at  night,  although  that  is  not 
characteristic.  There  may  be  at  the  same  time  or  later 
pains  in  the  shins,  a  place  where  one  does  not  often 
have  pains.  Near  the  time  of  the  eruption  the  hair  is 
very  apt  to  fall  out  and  the  person  may  become  tem- 
porarily bald.  The  glands  in  the  neck  and  elsewhere 
also  enlarge. 

In  the  later  stages  of  the  disease  not  only  the  sur- 
face of  the  body  but  the  internal  organs  are  affected, 
the  heart  with  syphilitic  aortitis,  described  in  one  of 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

the  earlier  chapters.  Syphilis  also  attacks  the  bronchial 
tubes,  and  sometimes  closes  one  bronchial  tube,  so  as  to 
throw  one  lung  out  of  business.  Syphilis  of  the  liver 
and  spleen  (usually  the  two  come  together)  —  are 
among  the  remaining  important  places  in  which  syph- 
ilis strikes  most  frequently  in  the  internal  organs. 

The  later  manifestations  of  syphilis  ("tertiary") 
consist  of  sores  called  gummata,  which  may  appear 
in  any  organ  of  the  body.  What  has  been  said  thus 
far  refers  to  particular  places  like  the  skin,  but  gum- 
mata may  come  absolutely  anywhere  in  the  body. 
They  have  been  seen  in  any  organ  we  can  name,  heart, 
liver,  brain,  bones,  skin,  etc.  There  are,  however,  cer- 
tain places  where  they  appear  most  often,  the  frontal 
bone,  about  the  elbows,  and  about  the  nose.  It  is  at 
this  stage  that  the  trouble  gets  deep  into  the  bones  of 
the  nose  so  that  the  nose  falls  in,  giving  what  is  called 
the  "saddle-nose"  of  the  person  who  has  no  bridge  to 
his  nose.  That,  however,  like  most  of  the  things  men- 
tioned, can  be  due  to  causes  other  than  syphilis. 

I  have  already  written  at  considerable  length  of 
tabes  and  paresis,  the  two  commonest  diseases  by 
which  syphilis  strikes  the  nervous  system.  They  come, 
as  a  rule,  years  after  the  primary  infection,  —  from 
ten  to  thirty  years,  —  and  it  is  these  patients  who 
most  often  can  perfectly  truthfully  say  that  they  have 
no  idea  that  they  ever  had  syphilis.  Only  in  recent 
years  has  it  been  recognized  that  there  is  a  definite 
connection  between  paresis,  tabes,  and  syphilis.  But 

3/2 


INFECTIOUS   DISEASES 

thefe  is  now  no  disagreement  among  medical  men  that 
they  are  always  due  to  this  single  cause. 

There  are  other  forms  of  syphilis  in  the  nervous  sys- 
tem, besides  tabes  and  paresis.  One  of  the  most  im- 
portant is  syphilis  of  the  base  of  the  bfain  where  the 
nerves  which  go  to  the  organs  of  sense,  especially  to  the 
eye,  come  out.  In  a  clinic  for  nervous  diseases  or  a 
syphilis  clinic,  we  are  pretty  sure  to  see  a  number  of 
individuals  with  one  eye  drawn  outward  or  vM|h  one 
eye  closed.  That  is  no  proof  of  syphilis,  but  it  is  sug- 
gestive, and  especially  when,  if  we  lift  the  dropped 
eyelid,  we  find  the  eye  pulled  outward.  That  means 
that  the  muscles  of  the  eye,  except  the  one  that  pulls 
the  eye  out,  are  paralyzed.  The  remaining  unpara- 
lyzed  muscle  overacts,  and  pulls  the  eye  outward. 
After  tabes  and  paresis  this  is  the  commonest  type  of 
syphilis  in  the  central  nervous  system. 

Syphilis  is  very  much  commoner  in  men  than  it  is  in 
women.  I  do  not  think  the  fact  has  ever  been  alto- 
gether accounted  for.  All  the  diseases  that  are  due  to 
syphilis  are  very  much  commoner  in  men.  In  races 
who  have  not  previously  had  the  disease  it  has  tremen- 
dous fatality ;  one  of  the  most  tragic  effects  of  the  con- 
tact of  what  we  call  civilization  with  a  savage  race  is 
the  spread  of  syphilis  and  the  tremendous  fatality  of 
the  disease  so  spread.  Its  spread  to  the  negro  and  to 
the  American  Indian  are  examples  of  what  I  mean. 
There  is  no  race  that  we  see  in  these  parts  which  has 
syphilis  with  anything  like  the  frequency  of  the  negro, 

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A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

and  it  is  generally  believed,  by  those  in  a  position  to 
know,  that  this  has  come  about  mostly  since  the  Civil 
War,  as  the  tremendous  commonness  of  tuberculosis 
in  the  negro  also  has.  On  the  other  hand,  one  of  the 
inexplicable  facts  is  that  the  negro  almost  never  gets 
some  of  the  results  of  syphilis,  especially  tabes.  Physi- 
cians who  practice  in  Southern  States  tell  us  that  while 
tabes  does  occur  in  negroes,  it  is  vastly  rarer  than  it  is 
in  the  white. 

The  question  is  often  asked,  "Can  syphilis  be 
cured?  "  I  do  not  think  anybody  is  in  a  position  to  give 
an  absolute  answer  to  the  question.  Syphilis  certainly 
can  be  made  to  disappear,  and  to  disappear  for  a  con- 
siderable period  of  years,  but  in  view  of  such  facts  as 
I  have  just  quoted,  —  i.e.,  the  occurrence  of  tabes 
twenty  or  thirty  years  after  the  original  infection,  — 
it  is  pretty  hard  to  say  positively  that  syphilis  is  ever 
cured.  In  the  great  majority  of  cases,  when  prop- 
erly treated,  —  that  is,  energetically  and  persistently 
treated,  —  it  can  be  made  to  disappear.  We  used  to 
have  absolutely  no  check  whereby  we  could  say  that 
a  patient  had  had  treatment  enough.  The  patients 
used  to  ask,  "  How  long  should  I  have  treatment?  "  and 
no  answer  could  be  given  them.  As  a  rule  we  used  to 
keep  the  patient  under  treatment  as  long  as  we  could 
keep  him  —  a  year  or  two,  and  we  had  no  good  reason 
to  suppose  that  he  needed  treatment  longer.  To-day 
we  feel  that  when  a  patient  has  had  a  negative  Wasser- 
mann  reaction  and  no  external  or  internal  evidence  of 

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INFECTIOUS  DISEASES 

syphilis  for  one  year,  we  are  ready  to  say  that  he  may 
marry  and  that  he  does  not  just  then  need  treatment, 
although  we  cannot  say  that  he  is  cured. 

The  Wassermann  test  has  about  it  a  great  deal  that 
we  do  not  know.  We  do  not  know  for  certain  that  a 
person  with  a  persistently  negative  Wassermann  re- 
action does  not  have  syphilis.  In  a  few  cases  we  have 
positive  evidence  of  syphilis  on  the  surface  of  the  body 
despite  a  negative  Wassermann.  Still  the  Wassermann 
is  the  best  guide  we  have  in  the  treatment  of  syphilis 
and  the  only  guide  until  late  years.  We  certainly  can 
overtreat  a  patient;  the  drugs  we  give  are  poisonous 
and  it  is  perfectly  possible  for  a  person  to  suffer  as 
much  from  the  treatment  as  from  the  disease.  It  is  not 
best,  therefore,  to  have  a  patient  go  on  indefinitely 
with  this  treatment. 

The  treatment  of  syphilis  now  consists  of  two  drugs 
which  have  been  tried  for  a  great  many  years,  and  one 
that  has  been  tried  for  only  a  few  years.  When  Ehrlich 
made  his  original  studies  with  salvarsan  in  animals,  he 
had  great  hopes  that  were  reflected  in  the  early  hopes 
of  physicians,  but  which  have  not  been  verified.  He  was 
able  in  animals  to  give  a  dose  of  salvarsan  which  would 
kill  all  the  germs  in  the  body,  and  he  spoke  at  that 
time  of  a  therapia  magna  sterilans,  or  a  great  sterilizing 
cure,  which  seemed  to  be  possible  in  the  early  stages. 
He  hoped  that  if  we  gave  one  great  dose  we  could  finish 
the  disease.  We  have  given  up  that  hope  now,  and  we 
have  witnessed  some  slight  reaction  against  salvarsan. 

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Now  we  are  settling  down  to  a  more  sensible  opinion. 
I  know  only  one  prominent  physician  who  does  not  use 
Isalvarsan;  I  know  no  physicians  who  do  not  use  the 
J  older  remedies,  mercury,  iodide  of  potash.  Social 
workers  hear  more  about  salvarsan  because  of  its  ex- 
pense and  because  they  are  often  asked  for  financial 
aid  for  this.  Salvarsan,  as  is  perhaps  generally  known, 
is  arsenic  and  nothing  but  arsenic,  so  combined  as  to  be 
fatal  to  most  of  the  germs  of  syphilis  without  being 
fatal  to  the  cells  of  the  body.  The  term  606,  which  is 
a  synonym  for  salvarsan,  means  that  this  was  the  6o6th 
combination  of  arsenic  with  other  chemicals  which 
Ehrlich  made  in  his  attempt  to  find,  what  he  finally  did 
hit,  a  substance  which  would  kill  most  of  the  germs  and 
not  prove  fatal  to  the  patient.  Neq^salvarsan  —  914 
—  was  his  next  discovery,  because  Ehrlich  did  not  stop 
with  606.  He  wanted  to  find  something  better  and 
cheaper.  But  it  is  worth  while  to  recognize  that  in  606 
we  are  dealing  with  arsenic,  so  that  we  give  it  for  per- 
nicious anemia  and  for  diseases  for  which  we  used  to 
use  arsenic  in  other  forms.  "914"  has  not  proved 
better  than  "606." 

To-day  there  is  practically  only  one  method  in  which 
salvarsan  is  given.  It  is  always  put  into  a  vein.  Up  to 
a  couple  of  years  ago  there  was  a  difference  of  opin- 
ion. We  used  to  put  it  into  the  muscular  tissues,  but 
that  is  now  discarded.  It  is  a  difficult  drug  to  get 
rightly  prepared.  Few  apothecaries  are  ready  to  make 
it  so  that  it  is  harmless;  there  are  a  great  many  slips 

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INFECTIOUS  DISEASES 

possible  which  make  the  drug  very  poisonous.  Few 
physicians  are  ready  to  give  salvarsan  in  their  offices 
unless  they  have  the  assistance  of  a  perfectly  reliable 
apothecary.  Neo-salvarsan,  on  the  other  hand,  is 
much  less  dangerous  and  much  less  difficult  to  mix  up. 
Hence  it  is  used  in  some  doctors*  offices  where  salvar- 
san is  not.  But  neo-salvarsan  is  less  effective  against 
syphilis.  Besides  the  difficulty  of  mixing  salvarsan,  we 
must  avoid  the  difficulty  of  getting  it  into  the  tissues 
around  the  vein.  It  is  also  of  some  importance  to  put 
nothing  else  besides  salvarsan  into  the  vein,  —  no  air, 
for  instance,  and  no  dirt. 

I  speak  of  all  this  because  I  think  it  should  be  gen- 
erally known  that  to  give  606  is  a  considerable  process 
and  that  a  physician  must  have  considerable  time  and 
skill  to  do  it  successfully.  To-day  we  give  it  in  our  out- 
patient clinics  and  let  the  patient  go  the  same  day 
after  a  little  rest,  but  we  prefer  to  have  him  at  rest  for 
twelve  hours  after  the  injection.  The  after-effects  may 
vary  from  none  at  all  to  quite  considerable.  I  cannot 
state  what  percentage  of  people  have  no  after-effects, 
but  certainly  in  a  considerable  number  there  are 
rashes,  headaches,  vomiting,  pain,  fever,  or  "  collapse  " 
which  compels  the  person  to  give  up  for  a  day  or  two. 

No  one  but  a  physician  can  prescribe  salvarsan.  I 
think  a  layman  might  easily  become  trained  so  that  he 
would  know  more  about  giving  it  than  the  average 
physician,  but  certainly  its  use  should  be  confined  to 
those  who  have  been  trained  in  this  particular  process. 

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Of  course  the  decision  as  to  when  it  should  be  given 
should  be  made  by  a  physician.  We  used  to  feel  that 
the  taking  of  blood  for  a  Wassermann  test  was  a  pretty 
delicate  matter,  though  now  in  the  Massachusetts 
General  Hospital  it  is  being  taken  by  physicians, 
nurses,  students,  and  clinic  secretaries,  and  so  far  I 
have  heard  of  no  bad  results.  But  the  giving  of  sal- 
varsan  certainly  does  not  belong  in  that  class. 

Salvarsan  is  never  given  once  only;  it  is  generally 
given  somewhere  between  five  times  and  ten  times,  at 
intervals  varying  from  five  days  to  ten  days  or  two 
weeks  between  the  injections.  The  number  of  doses 
given  depends  upon  the  results  —  how  the  patient  re- 
acts, what  happens  to  the  Wassermann  reaction.  Be- 
tween these  spaced  injections  of  salvarsan  most 
physicians  now  give  mercury  at  the  same  time. 

The  number  of  ways  in  which  one  can  give  mercury 
to  a  syphilitic  is  very  great.  Unlike  salvarsan  it  can 
be  given  by  the  mouth,  rubbed  in  through  the  skin, 
introduced  subcutaneously,  or  into  a  vein.  The  ma- 
Hority  of  physicians  prefer  either  to  give  it  subcutane- 
jously  or  to  have  it  rubbed  in  through  the  skin.  There 
are  advantages  and  disadvantages  in  either  way.  If 
we  give  it  subcutaneously,  we  are  sure  it  is  given ;  on 
the  other  hand,  it  is  painful  and  the  patient  cannot  do 
it  himself.  Still,  I  think  the  majority  of  physicians  in 
hospitals  now  prefer  that  method,  and  use  it  more  than 
any  other,  the  reason  being  that  they  are  then  sure 
that  it  is  given.  Through  the  skin  by  inunction  it  is 

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INFECTIOUS   DISEASES 

given  by  taking  a  piece  of  mercury  ointment  about  the 
size  of  a  large  pea  and  rubbing  it  for  twenty  minutes  to 
half  an  hour  on  a  portion  of  the  skin  until  there  is 
nothing  to  see.  The  patient  can  do  that  himself,  but 
seldom  can  be  trusted  to  do  it  well.  He  does  it,  on  one 
side  of  the  chest  the  first  night,  then  on  the  other  side ; 
the  third  night  on  one  side  of  the  abdomen,  then  on  the 
other  side;  then  on  one  of  his  legs,  then  the  other;  and 
so  on  until  he  is  round  to  the  starting-point.  This 
changing  about  is  to  avoid  irritating  the  skin.  The 
great  disadvantage  of  this  method  is  that  it  is  dirty 
and  gives  up  the  advantages  of  secrecy.  People  using 
this  method  are  pretty  likely  to  get  found  out,  but 
it  has  the  advantage  of  being  painless  and  possible 
for  the  patient  to  carry  out  himself  with  very  little 
expense  for  the  medicine;  mercury  ointment  is  not 
expensive. 

Easier  than  either  inunction  or  injection  is  the  giving 
of  mercury  by  the  mouth,  but  it  is  the  least  effective 
method  of  the  three.  Doctors  give  it  in  that  way  when 
they  cannot  give  it  any  other  way.  Of  course  with 
inunction  we  never  know  how  much  we  are  giving,  the 
dose  cannot  be  accurate ;  by  the  mouth  or  subcutane- 
ousfy  it  can. 

Every  patient  is  warned  to  watch  for  symptoms  of 
overdose.  The  first  of  these  is  a  soreness  of  the  teeth 
on  striking  them  together;  that  comes  twenty-four 
hours  or  so  before  the  more  serious  result  of  inflam- 
mation of  the  mouth,  stomatitis,  with  increased  flow 

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of  saliva,  whence  the  term  " salivation/'  Our  grand- 
fathers never  thought  they  had  given  mercury  enough 
unless  they  had  salivated  their  patients.  Nowadays 
patients  do  not  take  kindly  to  the  idea  and  doctors 
try  their  best  to  avoid  it.  But  this  is  often  impossible 
unless  the  patient  obeys  the  direction  to  stop  treat- 
ment the  instant  there  is  any  soreness  of  the  teeth ; 
even  then  he  sometimes  will  have  trouble  afterwards. 

Mercury  and  salvarsan  are  given  for  practically  the 
same  purpose,  with  this  exception,  that  salvarsan  acts 
far  more  quickly ;  hence  in  a  very  contagious  patient, 
salvarsan  is  the  drug  to  give  as  a  public  health  meas- 
ure. We  call  neo-salvarsan  "emergency  salvarsan" 
because  we  can  keep  it  on  hand.  Salvarsan  or  neo- 
salvarsan  is  given  in  our  syphilis  clinic  to  every  conta- 
gious case ;  we  make  sure  of  at  least  one  dose  in  such 
cases.  It  will  often  dry  up  a  moist  lesion  in  twenty-four 
to  forty-eight  hours.  Mercury  acts  much  more  slowly, 
but  seems  to  help  in  certain  ways  that  salvarsan  does 
not  help.  The  patient  getting  both  is  better  off. 

Potassium  iodide  is  the  least  valuable  and  the  least 
given  of  the  three  in  modern  clinics.  Yet  I  can  remem- 
ber the  days,  within  ten  years,  when  medical  men  felt 
themselves  right  in  giving  iodide  of  potash  and  nothing 
else  to  a  syphilitic.  No  one  would  do  that  to-day,  yet 
it  will  dry  up  and  heal  up  superficial  lesions  quicker 
than  mercury,  —  though  more  slowly  than  salvarsan. 
It  is  to  be  given,  therefore,  in  cases  where  we  cannot 
get  salvarsan,  and  want  to  get  a  quick  effect  on  a  dan- 

380 


INFECTIOUS  DISEASES 

gerous  lesion.  It  does  not  cure  syphilis  at  all.  Mercury 
and  salvarsan  certainly  cure  to  a  certain  extent,  if  not 
wholly.  Potassic  iodide  is  given  by  the  mouth.  It  is 
not  a  difficult  drug  to  take,  and  has  no  very  serious 
results  from  overdose. 


CHAPTER  XV 

INFECTIOUS   DISEASES    (CONTINUED) 

MALARIA  is  one  of  the  best  understood  of  all  infections. 
It  is  due  to  an  animal,  not  a  vegetable  parasite  (in  or- 
dinary infectious  fevers  the  bacilli  are  vegetables  ac- 
cording to  the  present  classification).  The  cause  of 
malaria  is  very  different,  an  enormously  larger  organ- 
ism; and,  so  far  as  we  know,  it  does  not  live  at  all  out- 
side the  bodies  of  animals  including  man.  We  know 
now  that  there  is  but  one  way  in  which  human  beings 
get  it,  and  the  negative  side  of  that  knowledge  is  just 
as  important  as  the  positive. 

The  word  "malaria"  is  Italian;  it  means  "bad  air," 
and  the  old  view,  which  still  lingers  in  country  dis- 
tricts, was  that  it  was  something  in  the  night  air  that 
people  breathed  in.  We  can  understand  now  quite 
easily  how  that  was  accepted,  because  night  is  the 
time  that  mosquitoes  get  in  their  work.  We  know  to- 
day that  the  malarial  organism  is  transmitted  only  by 
mosquitoes  and  by  a  few  species  of  mosquitoes.  There 
are  several  ways  in  which  the  chain  of  events  whereby 
a  person  acquires  malaria  can  be  broken:  (i)  by  de- 
stroying the  species  of  mosquito  that  transmits  it  - 
we  do  not  need  to  destroy  all,  only  certain  species;  (2) 
by  preventing  ourselves  from  being  bitten  by  a  mos- 
quito which  has  previously  bitten  a  malarial  patient; 

382 


INFECTIOUS  DISEASES 

and  (3)  by  having  no  malaria  patients  for  a  mosquito 
to  bite.  All  these  ways  are  utilized,  but  the  last  is  the 
most  useful. 

If  we  can  once  cure  all  the  malarial  patients  in  a 
given  district,  then  it  does  not  make  any  difference 
how  many  malaria  mosquitoes  we  have,  there  is  nobody 
from  whose  blood  they  can  get  the  malarial  parasite, 
and  transmit  it  to  us.  In  malarial  districts  the  most 
important  single  precaution  which  a  healthy  individual 
can  take  is  to  take  small  doses  of  quinine  all  the  time. 
In  the  Canal  Zone,  where,  in  spite  of  every  effort,  they 
cannot  abolish  all  the  mosquitoes  or  all  the  malarial 
patients,  they  have  their  employees,  so  far  as  they  can 
control  them,  take  small  doses  of  quinine  continually. 
The  effect  of  this  is  that  if  one  is  bitten  the  germs  are 
killed  off  before  they  get  much  of  a  hold. 

Within  my  own  lifetime  as  a  medical  man  we  have 
gone  through  three  phases  in  Boston  and  vicinity  in 
relation  to  the  occurrence  and  frequency  of  malaria. 
In  1890  when  I  was  a  medical  student  there  was 
no  malaria  at  all  in  or  near  Boston,  except  what  was 
brought  in  from  the  West  Indies  or  from  Southern 
parts.  If  a  case  was  discovered  here  we  said  at  once, 
" Where  have  you  come  from?"  The  second  phase, 
which  was  at  its  height  about  ten  years  later,  about 
1900,  coincided  with  the  opening-up  of  a  good  many 
drains,  and,  what  people  did  not  perceive  so  clearly, 
the  opening-up  of  those  drains  by  Italian  workmen, 
some  of  whom  were  presumably  infected  with  malaria, 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

because  it  is  enormously  common  in  Italy.  Malaria 
occurred  especially  in  the  houses  near  the  drains,  and 
that  was  explained  on  the  miasma  theory ;  but  the  fact 
that  the  malaria  mosquito  never  flies  many  yards  ex- 
plains it  much  better.  First,  the  Italians  were  bitten 
by  the  mosquitoes  and  then  the  people  near  by.  Right 
round  the  Massachusetts  General  Hospital  there  was 
a  good  deal  of  malaria  in  1900.  Now  we  find  it  hard  to 
establish  the  presence  of  any  cases  of  malaria  there.  It 
has  died  out  again  very  fast.  There  still  is  malaria  in 
the  suburbs  of  Boston  and  along  the  Charles  River,  but 
far  less  than  there  used  to  be,  so  that  one  requires  far 
more  evidence  for  proof  now. 

The  diagnosis  of  malaria  should  never  be  in  doubt. 
It  is  one  of  the  few  diseases  which  is  easy  to  recognize, 
because  we  have  an  absolute  criterion,  the  presence  of 
the  parasite  in  the  blood.  A  person  whose  blood  does 
not  contain  the  malarial  parasite  has  no  malaria.  It  is 
true  that  it  needs  a  little  practice  to  recognize  this 
parasite,  but  not  much,  and  there  is  no  excuse  for  any 
wrong  diagnosis.  A  great  many  wrong  diagnoses  are 
made,  simply  because  the  blood  is  not  examined.  One 
of  our  first  duties,  therefore,  is  to  find  out  whether  the 
blood  of  any  person  suspected  of  having  malaria  has 
been  examined.  If  it  has  not  been  examined,  there  is 
no  certainty  of  the  diagnosis,  and  if  it  has  been  ex- 
amined, there  ought  to  be  no  doubt. 

There  are  three  forms  of  malaria.  In  the  southern 
part  of  this  country,  and  in  the  tropics,  all  three  exist. 

384 


INFECTIOUS   DISEASES 

In  New  England  and  the  northern  half  of  the  United 
States  generally,  we  have  only  one  type  —  the  tertian 
type,  which  is  so  called  because  the  fever  comes  every 
third  day,  provided  you  count  both  ends.  It  comes 
every  other  day.  It  is  possible  to  have  two  generations 
of  malarial  organisms  living  in  our  blood  at  the  same 
time;  the  first  lives  forty-eight  hours,  born  the  first 
day,  lives  until  the  third,  and  then  starts  again.  An- 
other generation  starts  on  the  second  and  lives  until 
the  fourth,  and  so  we  have  two  sets  and  a  chill  every 
day,  one  set  on  the  first,  third,  and  fifth  day,  the  other 
on  the  second,  fourth,  and  sixth. 

Pretty  much  everybody,  I  suppose,  knows  the  fa- 
miliar group  of  symptoms,  chill,  fever,  and  sweat.  The 
temperature  which  has  been  normal  up  to  a  few  hours 
before,  suddenly  rises  within  a  few  hours,  say  to  104° 
or  thereabouts,  and  during  that  stage  the  patient  feels 
very  cold ;  then  he  feels  very  hot,  his  temperature  goes 
down,  and  he  perspires  freely.  He  will  shake  during 
the  chill,  and  has  a  good  many  other  symptoms,  such 
as  vomiting,  blueness  of  the  hands,  and  headache.  The 
essential  facts  are  given  us  by  the  thermometer,  and  by 
the  fact  that  next  day  he  is  all  right.  A  person  very 
sick  one  day,  all  right  the  next,  very  sick  the  third,  and 
all  right  the  fourth,  can  practically  only  have  one  dis- 
ease ;  but  still  the  only  proof  is  the  examination  of  the 
blood. 

Tertian  malaria  is  one  of  the  easiest  of  all  diseases  to 
cure.  There  is  no  excuse  for  not  curing  a  case  of  it,  and 

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a  case  which  is  said  to  resist  treatment  or  to  be  uncured 
by  quinine  is  not  malaria.  It  may  be  of  interest  to 
inquire,  "Then,  what  is  it?"  Curiously  enough,  it  is 
often  advanced  phthisis.  I  have  again  and  again  been 
called  to  examine  the  blood  in  supposed  malaria,  and 
have  found  advanced  tuberculosis,  undiscovered  before 
because  the  chest  had  not  been  examined.  Or  the  true 
diagnosis  may  be  a  deep  abscess  somewhere  in  the 
body,  which  causes  irregular  chills,  somewhat  but  not 
much  like  those  of  malaria  —  irregular,  not  every 
third  day. 

The  other  type  of  malaria  often  seen  in  the  southern 
part  of  this  country,  practically  never  seen  here,  is 
called  the  estivo-autumnal.  That  is  a  very  much  more 
serious  disease,  and  is  the  cause  in  tropical  countries  of 
a  great  many  deaths,  as  it  was  in  the  digging  of  our  own 
Panama  Canal.  It  causes  fever  which  has  no  fixed  type 
like  the  tertian,  but  may  run  continuously  for  two  or 
three  weeks  without  ever  dropping  to  normal  at  all, 
or  may  drop  every  four  or  five  days  and  then  go  up 
again.  There  is  no  fixed  type.  The  diagnosis,  there- 
fore, depends  wholly  upon  the  examination  of  the 
blood  for  parasites.  Now  and  then  we  have  made  bad 
mistakes  in  cases  that  were  brought  to  the  Massachu- 
setts General  Hospital.  We  were  not  looking  for  this 
fever  which  never  occurs  here,  failed  to  examine  the 
blood  carefully,  and  treated  the  cases  for  something 
else,  especially  for  typhoid. 

This  type  of  malaria  does  not  yield  always  to  qui- 

386 


INFECTIOUS  DISEASES 

nine,  and  there  are  cases  which  die  in  spite  of  quinine, 
because  the  parasites  accumulate  in  the  brain  and 
cause  brain  symptoms  which  are  fatal. 

A  few  words  on  the  characteristics  of  the  mosquito 
that  means  business  in  respect  to  malaria  as  contrasted 
with  the  harmless  forms  of  mosquito.  If  we  kill  any 
ordinary  mosquito  and  look  at  him  carefully,  we  find, 
nine  times  out  of  ten,  that  we  have  killed  a-  perfectly 
harmless  animal  so  far  as  malaria  is  concerned  —  one 
of  the  kind  called  culex.  There  are  three  characteristic 
points  about  the  culex:  (i)  when  he  stands  he  stands 
on  all  fours,  all  sixes  rather,  with  all  his  legs  down ;  (2) 
he  has  stripes  on  his  legs  like  a  Princeton  man;  (3)  he 
has  wings  that  are  not  spotted.  This  is  the  harmless 
culex  in  contrast  with  the  dangerous  anopheles.  When 
he  stands  (i)  he  stands  on  four  legs  and  kicks  up  behind 
the  other  two  legs;  (2)  his  legs  have  no  stripes;  and  (3) 
his  wings  are  spotted.  In  the  culex  the  wing  is  simply  a 
stripeless  web;  in  the  anopheles  we  can  see  spots  with 
the  naked  eye,  but  more  clearly  with  a  glass. 

To  kill  off  mosquitoes  is  part  of  public  health,  and  so 
near  to  every  one's  interests.  The  essential  thing  is  to 
prevent  their  breeding.  Killing  the  ones  that  we  see 
is  some  satisfaction  to  us,  but  does  no  good.  To  have 
any  effect  on  numbers  we  must  stop  their  breeding. 
They  always  breed  in  stagnant  water,  and  in  fresh 
water,  not  in  salt.  In  a  stream  or  in  a  lake  that  has 
stagnant  pools  around  its  edge,  they  will  breed.  They 
cannot  breed  unless  they  can  come  to  the  surface  of 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

the  water,  and  they  cannot  do  this  if  the  surface  of 
the  water  is  coated  with  kerosene.  So  we  pour  kerosene 
on  all  the  pools  of  water  that  we  cannot  dry  up  —  in 
the  cans  outside  the  woodshed  as  well  as  in  the  more 
obvious  pools.  We  cover  with  kerosene  every  body  of 
stagnant  water  out  of  doors. 

Every  patient  with  malaria  should  be  screened  so 
that  the  mosquitoes  cannot  bite  him,  not  only  for  his 
own  sake,  but  still  more  for  the  sake  of  the  rest  of 
us  who  may  get  some  of  his  germs  transmitted  by 
mosquitoes. 

Q.  Does  every  one  bitten  have  the  disease? 

A.  No;  certainly  not.  A  person  may  have  the  parasites  in 
the  blood  and  not  suffer  from  the  disease.  There  are  certain 
villages  in  Central  Africa  in  which  physicians  have  found 
almost  every  single  child  infected,  and  yet  most  of  them 
perfectly  healthy  and  free  from  symptoms.  Parasites  are 
in  their  blood  but  harmless  to  them,  so  that  we  could  not 
say  that  these  children  have  the  disease.  These  malaria 
carriers  —  infected  but  healthy  —  are  dangerous  to  others. 
Mosquitoes  bite  the  carrier  and  transfer  parasites  to  others 
not  immune.  In  them  the  symptoms  of  disease  may  be  seen. 

In  the  blood  the  organism  attacks  the  red  corpuscles 
and  eats  them  up;  having  eaten  one  it  migrates  to 
another.  Each  generation  is  born  and  dies  in  forty- 
eight  hours.  When  a  generation  is  born,  fifteen  to 
twenty-five  at  a  time  from  each  parent  cell,  that  is  the 
chill,  because  we  are  suddenly  attacked  by  fifteen  to 
twenty-five  times  as  many  as  there  were  before,  — 
that  is,  in  the  tertian  type. 

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INFECTIOUS  DISEASES 

Quinine  is  a  specific;  that  is,  it  will  cure  every  case 
of  the  tertian  type,  and  practically  every  case  of  the 
estivo-autumnal  type  if  it  is  taken  in  time.  We  can 
watch  the  action  of  the  quinine  in  the  blood  by  giving 
it  to  a  person  who  has  malaria,  and  seeing  the  germs 
under  the  microscope  shrivel  up  and  die  as  they  meet 
the  circulating  quinine.  It  is  perhaps  worth  while  to 
say  that  quinine  is  a  purely  chance  discovery,  the  ex- 
tract of  the  inner  bark  of  a  tree  which  happens  to  have 
been  found  by  monks  centuries  ago,  not  searching  on 
any  rational  principle,  but  as  nearly  by  chance  as  any- 
thing we  know. 

Q.  How  far  North  does  the  more  dangerous  type  come? 

A.  About  to  Mason  and  Dixon's  line.  There  is  plenty  of 
dangerous  malaria  in  Baltimore,  but  practically  none  in 
New  York. 

Malaria  is  one  of  the  diseases  that  ought  to  be  en- 
tirely exterminated.  It  is  easier  and  cheaper  to  ex- 
terminate than  any  other  disease  that  we  know,  by  the 
recognition  and  treatment  of  all  patients,  and  by  the 
draining  of  all  pools  and  ponds  in  the  neighborhoods 
known  to  be  especially  inhabited  by  the  anopheles 
mosquito. 

Septicemia,  or  sepsis,  is  blood  poisoning.  Septic  and 
emia  —  both  familiar  roots  to  us ;  septic  means  poi- 
soned ;  the  emia  root  means  blood ;  and  it  is  a  literal  and 
proper  account  of  what  the  disease  is  —  blood  poison- 

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ing  by  germs,  not  by  any  other  poisons,  and  not  by  any 
or  all  germs,  but  by  the  germs  which  produce  pus, 
chiefly  by  streptococci  which  grow  in  chains,  or  by 
staphylococci  which  grow  in  bunches.  Those  organisms 
are  with  us  all  the  time.  I  do  not  suppose  there  is  a 
person  living  who  has  not  got  them  in  the  mouth  and 
in  the  skin.  We  have  them  even  when  we  wash  our 
hands  carefully;  we  wash  off  only  the  gross  dirt  and 
germs.  Absolute  cleanliness  of  the  skin  is  an  impossi- 
bility, because  these  germs  are  in  the  skin  as  well  as  on 
it.  The  staphylococcus  cannot  be  got  out  in  any  way 
whatever.  The  streptococcus  is  in  the  mouth  and  can- 
not be  got  out.  There  is  no  use  in  trying  to  avoid  these 
germs,  but  they  are  ordinarily  harmless  because  they 
do  not  penetrate  into  the  blood.  Once  they  are  free  in 
the  blood  we  have  a  very  serious  disease,  septicemia. 
The  ordinary  cut  or  wound  of  the  hand  or  of  any  sur- 
face of  the  body  contains  these  germs;  that  is  why 
there  is  suppuration  in  it,  pus  in  it.  Ordinarily  they 
do  not  penetrate  farther.  But  at  any  time  we  may 
hear  that  the  wound  has  "gone  septic,"  or  that  the 
patient  has  a  "septic  hand"  or  foot  or  neck.  This 
means  that  the  cocci  have  broken  through  into  the 
interior  of  the  body  and  into  the  blood  stream. 

Sepsis  is  of  all  degrees  of  severity.  Probably  most 
persons  who  have  any  fever  at  all,  in  connection  with  a 
wound  or  operation,  have  septicemia  of  a  mild  type. 
But  ordinarily  the  body  very  soon  kills  off  these  germs 
in  the  blood,  and  nothing  serious  results.  If  they  be- 

390 


INFECTIOUS  DISEASES 

come  accustomed  to  living  in  the  blood,  —  if,  that  is, 
the  blood  loses  its  power  to  kill  them  off,  so  that  they 
stay  and  multiply  there,  —  we  have  the  dangerous  form 
of  septicemia. 

Wound  sepsis  is  the  commonest  type,  and  is  common 
in  proportion  to  the  difficulty  of  cleaning  out  a  wound. 
Many  of  us  have  heard  of  the  tremendous  proportion 
of  sepsis  in  the  wounds  now  seen  in  France,  because 
septic  material,  such  as  fragments  of  clothing,  are  car- 
ried into  the  wound  and  cannot  soon  be  cleaned  out. 
That  means  sepsis  and  a  high  death-rate. 

Next  comes  operative  sepsis.  Every  surgeon  fears 
and  fights  sepsis.  He  does  all  he  can  to  sterilize  his 
hands,  his  gloves,  his  dressings,  his  instruments,  his 
ligatures,  and  the  patient's  skin.  But  despite  all  pre- 
cautions wounds  occasionally  "go  septic."  The  num- 
ber of  cases  in  which  this  happens  is  diminishing  every 
year,  and  it  is  more  and  more  thought  that  some  slip 
in  the  technique  of  asepsis  is  made  in  the  case,  or  the 
wound  would  not  be  septic.  In  the  older  fiction  most 
of  us  must  have  noticed  references  to  a  "  heal  thy  sup- 
puration" in  wounds  and  after  operations.  We  have 
no  "healthy  suppuration"  nowadays  if  a  wound  is 
kept  properly  clean. 

Puerperal  sepsis  is  the  poisoning  of  the  blood  stream 
through  the  wounded  surface  of  the  uterus  af ten  child- 
birth. Many  cases  occur  also  after  abortions,  because 
septic  material  is  put  into  the  uterus  in  the  attempt 
to  bring  about  the  abortion.  (See  page  184.) 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

Septicemia  also  comes  about  in  connection  with  dis- 
eases of  the  heart,  when  bacteria  are  colonized  upon 
the  heart  valves  and  spread  thence  by  the  blood 
stream  to  all  parts  of  the  body.  In  those  cases  we  do 
not  always  know  how  the  germ  gets  in.  Perhaps  some- 
times it  enters  by  the  tonsils,  and  thence  spreads, 
through  the  blood  stream,  to  the  heart.  The  fever 
which  is  so  common  in  the  heart  troubles  of  children 
is  a  sepsis  similar  to  the  puerperal  or  operative  types. 

In  deep  abscesses  which  cannot  be  drained,  or  have 
not  been  drained,  septicemia  develops.  An  example  of 
that  is  the  deep  abscess  in  the  lungs  of  the  tuberculous 
patient.  The  tuberculous  patient  suffers  only  in  part 
from  the  tubercle  bacilli.  The  lung  cavities  are  in- 
vaded by  the  staphylococcus  and  streptococcus  on  top 
of  the  tubercle  bacilli,  and  most  of  the  severe  symp- 
toms, the  night-sweats,  fever  and  emaciation  of  tuber- 
culous persons  are  due  to  septicemia.  We  cannot  drain 
those  cavities  surgically;  the  patient  drains  them  par- 
tially by  coughing,  but  cannot  drain  them  thoroughly. 
Hence  in  the  advanced  stages  of  tuberculosis  we  are 
dealing  really  with  sepsis  in  the  lung. 

Bacilli  from  the  intestine  get  into  the  gall-bladder 
and  biliary  ducts,  and  set  up  their  suppurations  in  the 
gall-bladder,  and  from  there  sometimes  in  the  liver.  It 
may  be  impossible  to  drain  them,  because  there  may 
be  so  many  abscesses  in  the  liver  that  we  cannot  drain 
them  all,  and  a  fatal  septicemia  comes  about  in  that 
way.  There  are  deep  abscesses  of  the  kidney  and  of  the 

392 


INFECTIOUS  DISEASES 

prostate  gland,  the  result  of  which  if  not  properly 
drained  is  sepsis. 

In  all  these  cases  the  symptoms  are  a  good  deal  like 
malaria,  but  not  so  regular.  There  are  chills,  fever, 
sweats,  but  on  no  precise  plan.  Two  or  three  chills  may 
occur  in  one  day  and  then  none  for  a  day  or  two.  The 
type  of  fever  we  expect  is  what  is  called  a  "picket- 
fence"  temperature,  because  of  the  looks  of  the  chart. 
The  temperature  oscillates  rapidly  from  high  to  low, 
not  steadily  persisting  day  and  night  as  in  typhoid. 
"A  septic  chart,"  the  nurse  shows  us.  The  patient 
does  not  necessarily  feel  very  sick.  He  sometimes  does 
not  feel  sick  at  all,  though  he  is  a  little  weak.  He  often 
has  a  good  appetite,  and  generally  no  pain,  but  that  is 
about  the  only  good  thing  you  can  say  about  the 
disease.  His  strength  gradually  ebbs  away. 

The  prognosis  depends  on  the  possibility  of  surgical 
drainage  and  on  the  patient's  own  individual  vital  re- 
sistance. We  have  no  medicinal  treatment  whatsoever. 
If  the  sepsis  is  due  to  a  wound,  we  can  drain  that 
wound,  and  if  to  an  abscess,  we  can  open  that  abscess, 
and  the  patient  may  get  well.  But  if  those  conditions 
are  not  present,  the  patient  will  probably  die,  although 
at  any  time  the  person's  own  resistance  may  assert 
itself. 

I  have  sufficiently  described  septicemia  in  the  nar- 
rower sense,  as  we  ordinarily  use  the  word,  due  to 
streptococci  or  to  staphylococci,  or  to  both  at  once. 
We  also  use  "  sepsis"  in  the  broader  sense  to  mean  the 

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A  LAYMAN'S  HANDBOOK  OF   MEDICINE  t 

invasion  of  the  blood  stream  by  any  baccillus.  For 
instance,  the  pneumococcus  gets  through  into  the 
blood  stream  very  often ;  probably  most  cases  of  pneu- 
monia have  a  septicemia.  So  with  typhoid,  with  an- 
thrax, and  with  tetanus.  We  could  speak  of  these  dis- 
eases as  septicemia,  but  as  a  rule  we  do  not. 

Erysipelas  ("St.  Anthony's  Fire")  is  due  to  the 
streptococcus,  the  same  organism  that  I  have  men- 
tioned frequently  in  connection  with  heart  disease, 
kidney  disease,  tonsillitis,  and  septicemia.  In  erysipe- 
las, for  reasons  that  we  do  not  understand,  this  strep- 
tococcus runs  along,  like  a  prairie  fire,  just  underneath 
the  skin  and  produces  a  shallow  inflammation  with 
absorption  of  poisons  and  general  streptococcus  sep- 
ticemia, more  or  less  serious.  After  one  has  seen  a  few 
cases,  one  can  recognize  it  simply  by  the  appearance  of 
the  skin.  The  trouble  starts  usually  on  the  side  of  the 
nose  or  near  the  eye,  somewhere  about  the  central  part 
of  the  face.  It  starts  as  a  small  patch,  very  bright  red 
and  slightly  raised  above  the  surface.  Then  that  grad- 
ually spreads  in  all  directions  until  it  may  cover  the 
whole  face  and  neck,  but  rarely  goes  farther.  The  skin 
is  swollen  so  that  the  eyes  are  closed,  and  the  whole 
face  puffy.  At  the  end  of  the  disease  there  is  peeling,  as 
in  a  person  who  has  been  very  much  sunburned.  The 
local  inflammation  is  not  of  any  great  importance ;  the 
serious  part  of  it  is  when  the  streptococcus  gets  loose 
in  the  blood  stream  to  some  extent,  usually  to  a  very 

394 


INFECTIOUS   DISEASES 

slight  extent.  In  the  great  majority  of  cases,  if  the 
person  is  in  good  health  at  the  outset,  he  gets  well. 
The  disease  is  serious  only  if  it  attacks  people  who  are 
greatly  weakened  by  some  previous  trouble.  Old  peo- 
ple with  weak  hearts,  kidney  trouble,  or  diabetes  die 
of  this  disease  with  what  we  call  a  "  terminal  infection." 
We  are  afraid  of  erysipelas,  therefore,  in  old  people;  we 
are  not  afraid  of  it  in  others.  As  a  rule  it  is  perfectly 
harmless  in  middle-aged  or  young  people  who  have  no 
previous  disease,  though  occasionally  it  leaves  slight 
scars  on  the  skin. 

It  has  no  definite  course ;  it  may  last  a  few  days,  may 
last  two  or  three  weeks,  but  it  stops  of  itself  when  it 
gets  ready.  Every  sort  of  medicine  has  been  painted 
on  the  skin ;  I  have  seen  at  least  a  dozen  remedies  tried 
out,  but  none  of  them  had  the  slightest  effect.  Some 
day  we  shall  probably  get  an  anti-erysipelas  serum  like 
the  anti-diphtheritic  serum,  but  we  have  nothing  of 
value  yet.  Nothing  painted  on  the  skin  will  ever  have 
any  effect  because  the  disease  is  too  deep-seated. 

Q.  Does  it  occur  only  on  the  face? 

A.  No;  that  is  the  commonest  site,  but  it  may  occur  in 
other  places,  on  the  leg  or  around  the  edge  of  a  wound. 
Some  people  have  it  again  and  again.  I  had  a  choreman 
who  had  three  or  four  attacks  and  never  once  went  to  bed 
with  it.  With  him  it  started  on  one  ear,  and  that  is  a  fairly 
common  starting-place. 

Tetanus  ("lock- jaw")  is  due  to  a  bacillus  which  is 
very  common  in  all  sorts  of  places,  especially  in  gar- 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

den  soil,  but  ordinarily  quite  harmless  because  it  will 
not  grow  unless  it  is  deprived  of  oxygen.  It  won't 
grow  on  the  surface  of  the  body,  or  in  any  open 
wound,  does  not  multiply  at  all  on  the  soil  on  the  sur- 
face of  the  earth ;  but  only  when  it  is  deprived  of  oxy- 
gen; as,  for  example,  when  it  is  driven  deep  into  a 
wound  in  the  body.  That  is  why  we  are  afraid  of  deep, 
penetrating  wounds  which  cannot  be  probed  open. 
That  is  why  early  in  the  Great  War  there  was  such  a 
tremendous  amount  of  tetanus.  We  associate  it  with 
wounds  in  which  some  one  has  stepped  upon  a  needle 
or  a  nail,  and  driven  it  deep  into  the  foot,  but  it  is  the 
same  in  every  part  of  the  body. 

The  disease  itself  is  sufficiently  described  by  the 
familiar  term  "lock-jaw,"  which  is  a  spasm  of  the 
muscles  with  which  we  bite,  a  spasm  of  the  chewing 
muscles,  so  that  the  jaws  become  fixed.  The  cramp  is 
not  confined  to  those  muscles  and  this  cramp  in  itself 
is  not,  of  course,  very  serious.  We  can  feed  patients 
through  the  nose,  or  pull  out  their  teeth.  But  the  seri- 
ous thing  is  the  spread  of  the  bacilli  or  their  poisons 
beyond  the  point  of  entrance.  This  results  in  convul- 
sions, exhaustion,  and  death. 

Two  things  we  can  do  to  cure  or  to  avoid  tetanus :  in 
the  first  place,  to  be  sure  that  any  deeply  penetrating 
wound  is  widely  opened  so  that  the  air  can  get  in.  One 
sees  now  and  then  a  child  who  has  stepped  on  a  nail, 
with  a  resulting  little  scratch  that  does  not  bleed  at  all. 
But  if  we  know  that  the  nail  has  gone  in  a  half-inch  or 

396 


INFECTIOUS  DISEASES 

more,  we  cannot  do  a  more  important  thing  than  to  get 
that  child  to  a  surgeon  and  get  that  puncture  widely 
opened.  Once  that  is  done  there  is  no  more  danger. 
Unless  it  is  done  there  is  always  danger.  We  should 
follow  up  every  deeply  penetrating  wound  and  see  that 
it  is  properly  opened  by  a  surgeon. 

The  second  thing  is  to  give  the  anti-tetanus  serum, 
discovered  at  the  same  time  that  the  anti-diphtheritic 
serum  was  discovered.  It  won't  often  cure  cases  after 
the  trouble  has  got  started,  but  it  will  prevent  the  de- 
velopment of  the  bacilli  if  it  is  given  as  soon  as  the 
wound  occurs.  A  great  deal  of  good  has  been  done  in 
the  European  War  by  giving  anti-tetanus  serum  before 
tetanus  occurs  to  people  whose  wounds  are  of  such  a  na- 
ture that  we  know  they  cannot  be  thoroughly  cleaned 
out.  If  a  cut  bleeds  freely,  it  is  not  likely  to  have 
tetanus;  the  blood  is  likely  to  carry  the  germs  out 
with  it. 

We  have  all  heard  of  the  great  number  of  cases  of 
tetanus  occurring  on  the  sixth  or  seventh  of  July;  that 
is,  about  three  days  after  the  Fourth  of  July.  The 
germs  are  carried  in  by  a  toy  pistol  wad  ordinarily.  In 
this  country  the  vast  majority  of  tetanus  cases  are 
due  to  the  Fourth  of  July  wounds,  but  since  the  agita- 
tion against  this  form  of  celebration  there  has  been  a 
decrease  in  the  amount  of  tetanus.  More  than  half 
the  cases  die. 


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Questions  and  A  nswers 

Q.  Would  you  advise  a  person  who  had  such  a  wound  and 
could  not  get  to  a  surgeon,  to  open  it  himself? 

A.  Yes. 

Q.  Would  you  advise  every  case  of  a  person  who  ran  a 
needle  into  a  foot  or  finger  to  have  it  opened? 

A.  I  should. 

Q.  Even  if  the  needle  does  not  stay  in? 

A.  Yes ;  the  germ  stays  in  even  if  the  needle  comes  out. 

Anthrax.  We  have  had  nearly  a  dozen  cases  of  an- 
thrax in  the  Massachusetts  General  Hospital  within  a 
year,  which  is  more  than  we  have  had  in  twenty  years 
before  that.  It  has  a  very  definite  relation  to  occupa- 
tion, so  it  seems  to  me  that  all  social  workers  ought  to 
know  something  about  it.  It  is  a  disease  common  in 
sheep  and  cattle,  and  rare  in  human  beings.  In  Europe 
especially  it  has  at  times  killed  a  quarter  of  all  the 
sheep  or  cattle.  In  accordance  with  that  fact,  it  comes 
chiefly  in  those  human  beings  who  deal  with  hides  and 
wool.  It  used  to  be  called  "wool-sorter's  disease" ;  but 
in  this  country  it  comes  especially  from  hides  of  other 
sorts.  Most  of  the  cases  we  have  seen  this  year  have 
come  in  men  who  handle  or  carry  hides.  There  are 
anthrax  germs  in  the  hide  and  they  get  into  some  crack 
or  scratch  on  the  hands  or  more  often  in  the  neck. 

It  is  a  frequently  fatal  disease.  Starting  with  what 
looks  like  an  ordinary  boil,  a  pustule,  the  germ  gets 
loose,  multiplies  in  the  blood,  and  often  causes  death. 
We  should  always  follow  up  particularly  any  boil  or 

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INFECTIOUS   DISEASES 

sore  in  those  whom  we  know  to  be  engaged  in  jobs  that 
involve  the  handling  of  hides  either  of  sheep  or  of 
cattle,  and  in  those  who  handle  wool.  The  germ  also 
causes  a  pneumonia  when  it  gets  into  the  lungs,  and 
is  almost  invariably  fatal  when  it  does. 

From  a  practical  point  of  view,  all  we  need  to  bear 
in  mind  is  that  people  who  handle  hides  ought  to  be 
especially  careful  of  their  skin,  their  hands  and  faces 
and  necks,  where  they  come  in  possible  contact  with 
hides.  Surgeons  formerly  did  very  radical  operations 
on  cases  of  anthrax.  Now  there  is  a  growing  tend- 
ency to  let  them  alone,  because  surgical  interference 
may  spread  instead  of  checking  the  infection.  Good 
nursing  is  the  main  point. 

Questions  and  Answers 

Q.  Does  the  skin  have  to  be  broken? 

A.  I  do  not  believe  we  can  positively  answer  that.  The 
chances  are  that  the  same  thing  is  true  here  as  is  true  of  other 
infections,  that  those  minute  normal  openings  of  the  skin 
called  the  "hair  follicles"  are  sufficient;  those  openings  are 
microscopic,  but  large  enough  for  organisms  to  get  in.  I  do 
not  think  we  can  say  that  it  does  not  occur  that  way  with 
anthrax.  It  does  not  affect  any  other  person  unless  by  a 
transference  of  pus.  It  is  perfectly  possible  to  spread  it 
from  human  being  to  human  being  through  the  pus. 

Q.  Does  it  come  through  animals  that  had  anthrax? 

A.  Yes.  Anthrax  is  a  common  disease  in  sheep  and  cattle. 
There  is  no  particular  danger  from  eating  the  meat  of  these 
animals,  because  cooking  and  the  gastric  juices  are  our 
defense. 


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Leprosy  is  a  disease  which  it  is  almost  impossible  to 
catch,  but  unfortunately  the  public  has  very  much  the 
opposite  idea,  so  that  the  leper  has  been,  I  think,  dis- 
gracefully, very  expensively,  very  stupidly  treated,  by 
extreme  isolation  upon  such  islands  as  Penikese  and 
Molokai.  This  isolation  is  because  of  superstitions  on 
the  part  of  the  public  that  a  leper,  who  almost  never 
gives  anybody  disease,  should  be  shut  up  tight,  while 
syphilitics  and  the  tuberculous  go  free.  This  is  one  of 
the  paradoxes  and  abominations  of  our  system.  The 
Massachusetts  State  Board  of  Health  has  again  and 
again  pointed  out  to  our  State  Government  that  it  is 
very  unnecessary  to  keep  a  few  poor  lepers,  who  cer- 
tainly ought  to  be  kept  on  the  mainland,  isolated  for 
life  on  a  desolate  island.  But  a  very  unintelligent  and 
very  stubborn  prejudice  still  persuades  people  that 
leprosy  is  a  highly  contagious  disease.  It  is  not  impos- 
sible to  catch  it,  but  it  is  one  of  the  least  contagious  of 
all  the  diseases,  and  we  are  all  exposed  every  day  to 
more  contagious  ones. 

We  see  two  or  three  cases  a  year  in  the  Massachu- 
setts General  Hospital.  In  the  Orient,  it  is  very  com- 
mon, and  in  the  Hawaiian  Islands,  so  that  one  island 
there,  Molokai,  is  set  aside  for  the  isolation  of  the 
cases.  It  is  a  very  slow-going  disease,  lasting  twenty 
or  thirty  years,  and  patients  practically  never  die  of  it. 
They  die  of  the  exhaustion  which  makes  them  the  prey 
of  some  intercurrent  infection. 

It  attacks  the  face,  hands,  and  feet  with  a  slow- 

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INFECTIOUS   DISEASES 

going,  destructive  ulceration.  Features,  fingers,  and 
toes  may  finally  be  destroyed  by  it.  In  the  early  stages, 
when  it  is  most  important  to  recognize  it,  the  inexpert 
would  not  notice  it  at  all  except  that  these  patients 
may  seem  to  have  more  wrinkles  on  the  face  than 
others;  the  face  deeply  furrowed.  We  see  it  here  more 
often  in  negroes  than  in  any  other  race. 

I  think  the  disease  is  most  interesting  from  the  pub- 
lic health  point  of  view,  for  here  we  have  given  to  the 
State  Board  of  Health  the  power  to  put  a  person  out  of 
the  community  for  life  because  of  a  disease  which,  as 
I  have  said,  is  of  almost  no  danger  to  the  general  pub- 
lic. But  still  we  think  that  such  powers  ought  to  be 
held  by  the  State  Board  of  Health,  although  not  ap- 
plied to  this  rather  innocent  disease.  It  is  sometimes 
questioned  whether  the  State  has  any  right  to  deal 
in  this  way  with  individuals,  by  reason  of  their  infec- 
tion with  syphilis,  tuberculosis,  or  typhoid,  but  it  may 
be  pointed  out  that  we  are  already  doing  it  in  the  case 
of  one  feebly  contagious  disease,  leprosy. 

Ordinarily  a  leprous  case  is  passed  upon  by  a  coun- 
cil of  experts;  no  one  man  is  ordinarily  thought  suffi- 
cient to  make  such  a  tremendous  judgment.  In  Hawaii 
a  board  of  experts  passes  upon  the  lesions  and  examines 
them  microscopically  as  well  as  in  gross.  If  that  board 
is  certain,  there  is  no  appeal  from  it. 

Within  the  last  two  or  three  years  our  hopes  have 
been  aroused  by  work  done  in  the  Philippine  Islands 
by  United  States  public  health  officers  on  the  cure  of 

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leprosy.  I  do  not  think  anybody  can  say  that  we  have 
yet  found  a  cure  for  leprosy,  but  certainly  our  control 
of  the  disease  has  been  enormously  improved  during  the 
past  year  by  treatment  with  chaulmoogra  oil  as  worked 
out  in  the  Philippine  Islands.  Chaulmoogra  oil  is  an 
herbal  remedy  used  popularly  for  a  long  time,  but  not 
in  any  effective  way  until  of  late. 

Smallpox,  which  used  to  be  spelled  "pocks,"  as  I 
have  said  before,  is  one  of  the  best  examples  of  a  dis- 
ease which  we  have  now  conquered.  Along  with 
plague  and  yellow  fever  it  makes  a  respectable  trio  of 
diseases  which  there  is  no  reason  to  suppose  we  shall 
ever  have  again  in  civilized  communities  on  a  large 
scale.  Yet  in  a  city  like  Boston  we  are  always  in  dan- 
ger from  the  anti-vaccination  cranks,  who  labor  an- 
nually in  the  Legislature  to  repeal  the  law  for  the 
compulsory  vaccination  of  school-children. 

Smallpox  is  for  children  one  of  the  most  contagious 
of  all  known  diseases ;  for  adults  it  is  also  very  contag- 
ious. We  had  a  small  experience  of  it  in  Boston  a  few 
years  ago,  and  a  number  of  investigators  went  to  the 
hospital  where  the  patients  were  and  lived  there  (after 
vaccinating  themselves),  studying  the  disease  at  close 
quarters.  None  of  them  had  the  disease,  but  each  of 
them  had  at  least  one  pock,  one  lesion.  The  disease 
ordinarily  causes  the  patient  to  be  covered  with  a  mass 
of  suppurative  boils,  and  on  account  of  their  vaccina- 
tion these  investigators,  though  they  were  in  constant 

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INFECTIOUS  DISEASES 

contact  with  the  disease,  got  only  a  single  pimple.  They 
did  not  stop  work  and  were  in  no  danger,  but  they  left 
their  investigation  with  a  very  hearty  respect  for  the 
contagious  powers  of  the  disease.  We  have  not  seen  a 
case  for  two  years  in  the  Massachusetts  General  Hos- 
pital. But  in  cities  along  the  Canadian  border,  in  cities 
with  a  large  French- Canadian  population  and  no  com- 
pulsory vaccination,  there  are  frequent  small  epidem- 
ics. In  Kentucky  and  Tennessee  and  other  Southern 
States  also,  there  are  many  cases  every  year,  because 
they  have  no  compulsory  vaccination  there. 

The  two  diseases  that  smallpox  looks  like  are  acne 
and  chicken-pox ;  acne  means  the  ordinary  pimples  on 
the  face.  The  chief  difference  is  that  the  smallpox 
patient  is  generally  much  sicker.  Acne  and  chicken- 
pox  do  not  make  one  feel  sick.  But  the  patient  with 
smallpox  is  generally  febrile  and  weak  and  in  consid- 
erable pain  in  his  head  and  back. 

Certain  things  ought  to  be  said  about  vaccination, 
because  questions  are  often  raised  as  to  the  dangers  of 
the  process,  and  as  to  the  degree  of  protection  which 
it  gives.  In  the  first  place,  the  reason  that  the  anti- 
vaccinationists'  propaganda  gets  so  much  power  is 
that  people  are  afraid  of  having  some  disease  put  into 
their  blood.  I  suppose  the  disease  that  they  are  afraid 
of  is  syphilis.  I  do  not  know  of  any  well-authenticated 
case  where  a  person  has  had  a  syphilitic  lesion  on  the 
site  of  a  vaccination,  but  one  cannot  deny  the  possibil- 
ity of  such  a  lesion  provided  vaccination  were  done 

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with  criminal  carelessness.  The  other  thing  that 
bothers  people  is  the  fact  that  vaccination  sores  get 
septic,  sometimes  when  the  vaccination  is  clumsily 
done,  and  sometimes  when  it  is  correctly  done.  We 
need  not  necessarily  blame  the  doctor  because  the 
patient  has  a  bad  arm.  In  spite  of  all  precautions,  if 
the  patient  is  in  bad  condition,  any  break  in  the  skin 
may  become  septic. 

Christian  Scientists,  especially,  I  think,  feel  strongly 
on  the  subject,  and  the  question  of  their  right  to  live 
according  to  their  beliefs  has  often  come  up  in  terms  of 
freedom  —  the  kind  of  freedom  that  our  ancestors 
came  to  America  to  win.  It  seems  to  me  that  the  essen- 
tial point  is  this :  People  are  perfectly  free  to  go  unvac- 
cinated  and  live  their  own  lives,  so  long  as  they  will  live 
by  themselves,  and  not  endanger  the  rest  of  us.  A  man 
has  a  perfect  right  not  to  be  vaccinated  or  allow  his 
children  to  be  vaccinated,  provided  he  does  not  send 
his  children  to  the  public  schools  or  allow  them  to  mix 
with  others.  But  he  has  no  right  to  inflict  his  beliefs  on 
the  huge  majority  of  people  who  disagree  with  him. 
That  is  the  stand  that  Massachusetts  has  taken  so  far, 
but  as  I  have  said,  each  year  we  are  afraid  that  the 
cranks  will  win  out  at  the  State  House  and  that  the 
vaccination  law  will  be  weakened. 

The  usual  form  of  attack  on  the  compulsory  vaccina- 
tion law  is  the  proposal  to  allow  parents  their  own  free 
choice  as  to  whether  their  children  shall  or  shall  not  be 
vaccinated.  That  proposal  is  not  justifiable  I  think, 

404 


INFECTIOUS  DISEASES 

because  it  endangers  the  majority.  There  never  was  a 
case  where  scientific  evidence  is  clearer  than  in  regard 
to  vaccination.  We  have  no  reason  to  be  moderate 
or  modest  at  all  in  the  matter.  The  evidence  will  con- 
vince any  fair-minded  person  who  examines  it. 

Thorough  governmental  inspection  of  the  plants 
where  vaccines  are  made,  is  our  clear  right,  I  think.  I 
do  not  think  that  the  possible  dangers  of  sepsis  from 
unclean  vaccine  points  should  be  overlooked,  nor  do  I 
think  that  anybody  and  everybody  should  be  allowed 
to  manufacture  and  to  sell  vaccine.  There  has  also 
been  a  good  deal  of  question  about  state  manufacture 
of  vaccine  points  and  of  free  state  vaccination.  Cer- 
tainly the  fees  charged  for  vaccination  have  some- 
times been  excessive.  If  there  is  any  question  about 
people's  ability  to  pay,  vaccination  ought  to  be  done 
free  at  the  hospitals  or  elsewhere  by  the  State  or  by 
the  city. 

Questions  and  Answers 

Q.  Are  French-Canadians  or  negroes  more  likely  to  take 
smallpox? 

A.  It  is  only  because  they  do  not  get  vaccinated.  We  do 
not  know  any  reason  to  suppose  that  they  are  any  more 
prone  than  others  to  take  it. 

Q.  Is  there  any  reason  why  a  child  with  syphilis  should 
not  be  vaccinated? 

A.  No;  I  know  of  no  good  reason. 

Q.  How  long  does  protection  last? 

A.  The  only  safe  way  is  to  repeat  vaccination  whenever 
there  is  an  epidemic.  We  do  not  ordinarily  now  vaccinate 

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people  more  than  once  unless  in  the  presence  of  an  epidemic. 
Then  we  have  got  to  vaccinate  everybody  who  is  anywhere 
near  the  particular  case.  If  a  person  has  been  vaccinated 
and  it  does  not  ''take,"  he  should  be  vaccinated  at  least 
three  times  more  in  the  attempt  to  get  it  to  "take." 

Q.  Is  seven  years  the  limit  of  immunity? 

A.  I  do  not  think  there  is  any  good  reason  to  believe  that. 
The  number  seven  still  plays  the  part  of  a  magic  number  in 
certain  quarters,  but  I  do  not  think  there  is  any  evidence 
back  of  it.  Health  boards  do  not  usually  advise  adults  to  be 
vaccinated  unless  there  is  an  epidemic  in  sight. 


CHAPTER  XVI 

POISONS 

LEAD-POISONING  is  vastly  the  most  important  indus- 
trial disease.  I  think  it  can  be  said  to  be  the  only  com- 
mon industrial  disease  whose  existence  we  know  to-day, 
though  there  are  others  which  we  suspect.  We  are 
always  looking  for  evidence  of  poisoning  in  certain 
trades  concerned  with  lead,  —  especially  in  workmen 
who  manufacture  or  use  paint. 

There  is  a  great  difference  between  different  kinds  of 
painting  work.  All  painters  recognize  this  and  speak  of 
11  inside  jobs"  and  "outside  jobs"  as  very  different  in 
their  risks.  The  outdoor  jobs,  where  there  is  free  cir- 
culation of  air,  are  very  much  less  dangerous.  Lead 
goes  into  the  body  in  part  through  the  intestinal  tract 
(through  the  mouth)  and  by  respiration.  Sand-paper- 
ing-off  of  paint  containing  lead  is  one  of  the  most 
dangerous  jobs;  the  lead  dust  gets  into  the  air  and  is 
breathed  in.  Besides  painters,  a  great  many  workers 
in  iron  get  lead- poisoning  because  the  iron  which  they 
'handle  is  so  often  covered  with  lead  paint,  —  pig  iron 
may  be  covered  with  paint,  —  and  if  handled  much  has 
the  dangers  of  handling  lead.  When  people  set  type  by 
hand,  which  they  still  do  to  some  extent,  they  are  in 
danger.  We  used  to  think  of  printing  as  the  most  dan- 
gerous occupation  next  to  painting.  To-day  most  type- 

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setting  is  done  by  the  monotype  or  linotype,  and  that 
is  not  so  dangerous  as  the  older  way. 

In  this  part  of  the  world  certainly,  next  to  painters 
the  greatest  danger  is  among  rubber- workers.  I  sup- 
pose some  of  my  readers  may  be  as  innocent  as  I  re- 
cently was  in  thinking  that  if  we  are  dealing  with  rub- 
ber we  are  dealing  with  rubber  itself.  But,  in  fact,  pure 
rubber  is  almost  never  used.  Even  the  workmen  have 
sometimes  no  idea  of  what  is  mixed  with  the  rubber, 
and  are  perfectly  unconscious  that  they  are  dealing 
with  lead.  Litharge,  which  they  mix  with  the  rubber, 
is  a  lead  compound.  Of  course  not  everybody  who  is 
concerned  with  rubber  deals  with  lead,  but  in  the  mix- 
ing processes  they  do.  There  are  other  hazards  in  the 
rubber  industry,  but  so  far  as  lead  is  concerned  it  is 
chiefly  in  that  one  mixing  process. 

Next,  perhaps  the  most  common  source  of  lead- 
poisoning  is  drinking-water.  Not  many  years  ago  a 
change  took  place  in  the  water  supply  to  the  town  of 
Milton,  Massachusetts,  whereby  that  water  attacked 
the  lead  in  the  pipes,  and  produced  a  large  number  of 
cases  of  lead-poisoning  in  the  town.  Some  of  these 
patients  sued  the  city.  That  was  the  most  extensive 
outbreak  of  lead- poisoning  that  I  have  ever  known. 
Now  and  then  one  sees  it  away  up  in  the  country  where 
people  have  not  any  idea  that  there  is  any  possibility 
of  their  getting  lead.  On  one  occasion,  that  has  always 
stuck  in  my  memory,  I  found  a  whole  family  poisoned 
by  lead,  and  after  hunting  around,  found  the  weight  of 

408 


POISONS 

the  pendulum  of  an  old  clock  which  had  been  thrown 
down  the  well.  I  found  it  in  a  condition  showing  that  a 
good  deal  of  lead  had  come  off  it  since  it  first  fell  there. 

The  symptoms  of  lead-poisoning  are  often  masked 
for  a  long  time.  They  do  not  show  themselves  in  ob- 
vious ways  until  the  case  is  well  advanced.  The  earliest 
change  that  we  can  recognize  easily  is  in  the  blood. 
With  the  dyes  ordinarily  used  to  stain  blood,  we  get  a 
new  picture  in  the  blood  of  a  case  of  lead  poisoning. 
The  smooth,  yellow  face  of  the  red  corpuscle  becomes 
"  stippled,"  as  if  a  charge  of  shot  had  been  fired  into  it. 
In  most  medical  institutions  that  is  now  called  "  stip- 
pling," the  term  often  used  by  engravers  being  here 
applied  to  the  looks  of  an  affected  red  corpuscle.  That 
symptom,  of  course,  would  not  come  to  light  unless 
some  one  suspected  lead-poisoning,  for  stippling  is  not 
an  easy  thing  to  find  in  the  blood.  After  the  blood, 
the  gums  are  the  place  that  shows  lead  next.  Lead 
circulates  in  the  form  of  a  soluble  salt.  In  the  gums  it 
meets  the  products  of  food  decomposition  and  is  pre- 
cipitated right  in  the  gum  itself,  making  a  black  or 
gray  line  along  the  edge  of  the  gum  where  it  touches 
the  teeth.  If  a  man  has  no  teeth  he  has  no  lead-line,  no 
matter  how  much  poisoning  he  has.  It  may  occur  only 
on  the  inner  surface  of  the  teeth,  so  that  a  person  who 
does  not  look  for  it  very  carefully  with  the  mirror  won't 
find  it. 

Next  conies  colic,  intestinal  pain,  not  differing  in  any 
way  from  the  many  stomach-aches  to  which  the  popu- 

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lation  is  subject,  only  significant  in  a  person  exposed  to 
lead  and  not  accustomed  to  having  such  attacks.  They 
are  accompanied  by  constipation.  Next  comes  anemia, 
the  destruction  of  red  corpuscles  by  the  poison.  Only 
after  all  of  this  comes  the  thing  that  we  hear  most 
about,  the  "  wrist-drop,"  or  paralysis  of  the  muscles  of 
the  wrist.  I  have  not  seen  that  now  for  quite  a  long 
time.  A  case  never  ought  to  get  to  the  stage  of  wrist- 
drop.  It  ought  to  be  recognized  and  cured  before. 
Nevertheless  a  slight  weakness  of  the  forearm  muscles 
demonstrable  by  careful  tests  may  be  a  very  early 
symptom. 

Finally,  rarest  and  most  disgraceful  to  the  medical 
profession,  are  the  kidney  effects  and  brain  effects. 
The  effects  of  lead  upon  the  brain  may  give  an  illness 
like  meningitis,  and  may  be  fatal.  On  this  account 
there  are  deaths  from  lead-poisoning  every  year,  all 
of  course  preventable.  In  the  kidney  lead  produces 
chronic  Bright's  disease.  Through  this  and  through 
its  effect  on  the  arteries  it  also  weakens  the  heart. 

The  problem  of  preventing  lead-poisoning  ought  to 
be  a  very  simple  one,  but  in  fact  it  is  not.  The  reason 
is  that  it  takes  a  great  deal  of  trouble  on  the  workman's 
part  to  protect  himself,  and  as  he  does  not  get  hit  very 
often  or  very  severely  by  the  poison,  it  is  very  hard  to 
get  him  to  take  it  seriously.  We  harangue  patients 
about  taking  the  dusti  off  the  hands  before  they  eat, 
washing  the  djtist  carefully  off,  using  the  respirator, 
etc.,  but  almost  never  can  we  get  people  to  do  it. 

410 


POISONS 

If  the  disease  has  not  progressed  to  the  point  of 
wrist- drop  or  kidney  trouble,  we  can  usually  cure  it 
simply  by  stopping  the  source  of  poison.  Take  a  man 
away  from  the  trade  or  the  water  supply  from  which 
he  gets  lead,  and  he  recovers.  We  also  use  medicines, 
but  we  are  not  convinced  that  they  have  much  to  do 
with  the  cure. 

Q.  What  kind  of  paint  gives  lead  poisoning? 
A.  Almost  any  paint  that  has  any  body  to  it,  and  is 
opaque,  is  apt  to  contain  lead. 

Since  the  habit  of  cleaning  ladies'  gloves  with  gaso- 
line has  come  up,  we  see  a  good  deal  more  of  naphtha 
poisoning  than  we  used  to.  I  knew  of  two  girls  who 
fainted  because  they  inhaled  too  much  naphtha  while 
cleaning  gloves.  This  has  no  serious  effects,  so  far  as  I 
know,  but  we  do  not  know  much  about  the  chronic 
symptoms  that  may  result  from  inhaling  a  small 
amount  all  the  time.  In  garages,  etc.,  the  same  sort 
of  symptoms  occur,  and  it  is  quite  probable,  I  think, 
that  there  are  chronic  poisonings  as  well,  but  we  do 
not  know  much  about  them  as  yet. 

Acetanilid.  Now  that  drug  stores  sell  "headache 
powders'*  to  anybody  and  in  any  quantity  without 
prescription,  we  see  every  year  a  certain  number  of 
poisonings  by  acetanilid,  which  is  the  chief  ingredient  of 
most  headache  powders.  I  have  had  patients  who  have 
been  buying  a  box  a  week  right  along  for  a  year,  and 
thinking  it  was  just  like  buying  groceries.  They  some- 
times get  themselves  into  a  very  uncomfortable  condi- 

411 


.A  LAYMAN'S^  HANDBOOK  OF  MEDICINE 

tion,  and  there  have  been  occasional  fatalities.  One  of 
the  most  important  things  about  acetanilid  poisoning, 
that  occurs  in  relation  to  headache,  is  that  for  all  we 
know  the  headache  may  be  due  to  the  drug.  A  person 
begins  taking  the  drug  for  a  headache  which  was  due 
to  something  else,  but  it  is  perfectly  possible  that  the 
headache  he  now  has  is  due  to  the  drug,  for  if  he  leaves 
off  the  drug  he  often  gets  over  the  headache  as  well. 

The  permanent  presence  of  a  bluish  color  to  the  lips, 
such  as  we  see  temporarily  in  people  who  are  very  cold 
or  out  of  breath,  may  lead  us  to  suspect  acetanilid.  As 
soon  as  we  take  a  drop  of  blood  on  a  piece  of  blotting- 
paper  we  see  at  once  that  it  is  not  red,  but  brown. 
That  is  the  essential  point  in  the  diagnosis.  It  gets 
well  when  people  stop  the  drug,  although  rather  slowly. 
The  occasional  fatal  cases  are  from  single  large  doses 
taken  by  mistake. 

Acetanilid  is  a  very  valuable  drug  in  spite  of  these 
dangers,  and  can  be  perfectly  well  taken  in  such  a  way 
as  to  do  good  and  not  harm.  One  does  not  need  to  give 
up  taking  it  altogether. 

Alcoholism.  I  have  said  something  about  alcoholism 
in  connection  with  its  effects  on  the  brain  in  insanity, 
and  also  in  connection  with  diseases  of  the  nerves,  as  a 
cause  of  neuritis  and  paralysis,  but  there  still  is  a  good 
deal  more  to  be  said  about  it. 

We  divide  alcoholics  into  three  groups,  the  acute 
(the  ordinary  " Saturday  night  drunk"),  the  chronic 
steady  drinker,  and  the  periodic  drinker.  There  is  not 

412 


POISONS 

much  to  be  said  that  is  not  familiar  to  all  of  us  about 
the  symptoms  of  acute  alcoholism.  In  the  vast  major- 
ity of  cases  acute  alcoholism  is  not  dangerous  to  the  by- 
standers. The  "drunk"  has  far  less  muscular  strength 
than  usual  and  it  is  very  easy  to  push  him  over.  On  the 
other  hand,  there  are  a  certain  number,  especially 
those  made  drunk  on  impure  alcohol,  who  get  what  is 
popularly  called  "fighting  drunk"  or  "crazy  drunk," 
and  are  of  course  as  dangerous  as  any  other  powerful 
animal.  When  a  man  has  got  to  the  stage  of  being 
"dead  drunk,"  —  that  is,  of  being  unconscious  —  a 
great  many  difficult  decisions  arise  as  to  what  is  the 
matter  with  him.  There  was  a  most  interesting  article 
in  the  London  Lancet  years  ago  under  the  title  "  Drunk 
or  Dying?"  detailing  several  mistakes  in  both  direc- 
tions ;  a  man  thought  to  be  drunk  was  in  fact  dying,  or 
vice  versa. 

The  reason  so  many  mistakes  happen  is  that  the  man 
is  usually  taken  to  the  police  station  and  left  there  to 
sober  off,  either  with  no  medical  attendance  or  with 
the  political  doctor,  who  is  not  much  better  than  none. 
A  man  who  feels  sick  and  is  just  about  to  become  un- 
conscious from  apoplexy,  syphilis,  diabetes,  or  any  one 
of  a  number  of  causes,  often  takes  a  drink,  and  there- 
fore smells  of  liquor,  and  is  therefore  assumed  to  be 
drunk  when  he  is  found  unconscious.  As  already  said, 
it  may  be  a  very  difficult  thing  to  tell  whether  a  man  is 
dead  drunk,  or  very  seriously  ill,  or  both.  One  of  the 
simple  tests  which  will  sometimes  decide  is  the  temper- 


A   LAYMAN'S  HANDBOOK  OF  MEDICINE 

ature.  A  man  who  is  merely  dead  drunk  never  has  fever, 
though  he  may  have  fever  from  the  other  causes  simu- 
lating alcoholism. 

In  the  sobering-off  process  the  most  striking  thing  is 
the  tremor.  The  amount  of  coarse  shaking  that  there 
is  in  an  alcoholic  who  is  getting  over  a  drunk  is  some- 
times quite  alarming. 

There  was  a  recent  interesting  article  in  the  Boston 
Medical  and  Surgical  Journal,1  with  an  analysis,  from 
the  point  of  view  of  medicine,  of  one  hundred  cases  of 
chronic  alcoholism  as  seen  in  court.  There  was  hardly 
a  normal  individual  in  the  lot ;  I  mean  that  they  were 
abnormal  not  merely  because  of  alcohol,  but  by  reason 
of  previous  brain  disease.  The  great  majority  of 
chronic  alcoholics  are  alcoholic  because  they  were  ab- 
normal from  birth.  Feeble-mindedness  shows  itself  in 
many  ways,  and  one  of  them  is  in  alcoholism.  Slight 
attacks  of  insanity  may  show  themselves  in  alcohol- 
ism. Hysteria  or  epilepsy  may  do  the  same.  We  must 
realize  then  that  alcoholism  may  well  be,  and  in  the 
more  striking  court  cases  probably  is,  the  result  rather 
than  the  cause  of  the  man's  debilitated  make-up. 

President  Eliot,  near  the  end  of  his  thirty-five  years 
as  head  of  Harvard  College,  said  in  a  public  address 
that,  in  all  the  years  in  which  he  had  studied  the  prob- 
lem of  college  drinking,  he  had  seldom  if  ever  known  a 
man  who  drank  in  college  and  who  failed  to  straighten 

1  Victor  V.  Anderson,  M.D.,  "The  Alcoholic  as  Seen  in  Court." 
Boston  Medical  and  Surgical  Journal,  April  6,  1916. 

4T4 


POISONS 

out  and  behave  himself  afterwards,  unless  there  was 
something  wrong  in  his  inheritance.  If  the  college 
drinker  does  not  straighten  out  under  the  pressure  of 
professional  work  and  the  need  to  be  of  use  in  the 
world,  he  usually  turns  out  to  have  a  pathological 
inheritance. 

The  periodic  drinker  is  often  referred  to  as  the  "dip- 
somaniac." I  think  the  better  students  of  alcoholism 
do  not  use  this  term  much,  but  the  objective  facts  are 
that  individuals  who  are  perfectly  sober,  and  may  even 
be  total  abstainers  for  long  periods,  suddenly  find  them- 
selves, so  to  speak,  in  the  middle  of  a  debauch,  keep  it 
up  for  a  certain  period,  then  stop  and  have  apparently 
no  tendency  to  drink  until  after  a  certain  number  of 
weeks  or  months,  when  the  same  thing  recurs. 

We  hear  a  great  deal  of  the  physical  craving  for 
liquor.  I  do  not  believe  there  is  any  such  thing  except 
in  the  people  who  are  in  the  middle  of  a  drunk.  A  per- 
son who  has  slept  it  off  and  got  it  out  of  his  system  may 
well  go  back  to  it  and  of  course  often  does.  But  he  does 
not  go  back  from  any  merely  "physical  "  craving,  but 
generally  because  he  is  bored  or  because  he  is  blue  or 
because  he  is  restless.  Most  often,  I  think,  he  drinks 
because  he  has  a  general  sense  that  he  needs  something 
or  other  to  fill  up  a  vacancy,  but  this  is  not  chiefly  a 
physical  vacancy.  I  think  it  is  the  same  sort  of  thing 
that  makes  the  American  people  chew  gum  —  they 
want  to  be  doing  something;  they  are  not  sufficiently 
interested  in  life  without  abnormal  activity. 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE  ^ 

The  subject  of  the  moderate  drinker  has  been  dis- 
cussed a  great  deal.  Anybody  who  has  any  wide  ex- 
perience of  human  beings  knows  that  there  are  a  great 
many  people  who  take  a  moderate  amount  of  alcohol 
throughout  their  lives  without  any  demonstrably  bad 
results  upon  their  work  or  their  health.  At  the  same 
time,  anybody  whose  work  demands  a  high  grade  of 
efficiency,  either  of  mind  or  of  hand,  can  easily  demon- 
strate that  very  moderate  doses,  such  as  a  cocktail  or  a 
glass  or  two  of  beer  or  of  wine,  impair  his  efficiency  for  a 
certain  time.  Any  one  who  plays  an  instrument  or 
runs  a  typewriter  can  see  the  effects.  Hence  no  one 
who  wants  to  be  at  his  best  all  the  time  can  afford  to 
drink  at  all. 

One  point  more :  We  ordinarily  speak  of  alcohol  as  a 
"stimulant."  It  is  worth  realizing  that  it  is  univer- 
sally agreed  among  physicians  now,  that  it  is  never 
a  stimulant,  always  a  narcotic.  The  reason  it  seems 
to  be  a  stimulant  is  because  after  dinner  it  narcotizes 
our  inhibitions,  our  modesty,  so  that  our  tongues 
move  very  freely  and  often  very  fast.  Certain  activ- 
ities come  to  light  and  so  seem  to  be  stimulated; 
but  in  fact  the  brakes  are  taken  off  of  natural  self- 
restraint.  A  man  who  is  dead  drunk  and  snoring  with 
liquor  is  narcotized  in  an  obvious  way ;  the  man  who  is 
supposed  to  be  brilliant  after  dinner  is  also  narcotized, 
only  less  obviously. 

When  we  view  the  chronic  alcoholic  as  he  figures  as 
a  social  burden  and  problem  year  after  year,  and  study 

416 


POISONS 

the  mental  side  of  the  patient,  we  find  far  more  mental 
deterioration  as  a  cause  of  alcoholism  than  as  a  result  of 
it.  Of  course  that  means  that,  in  our  penal  and  sociolog- 
ical regulations  in  regard  to  the  alcoholic,  we  are  trying 
to  punish  a  man  who  is  not  responsible  and  can  get 
no  benefit  by  punishment,  or  indeed  from  any  moral 
appeal.  He  has  no  power  to  resist.  If  we  were  to  treat 
chronic  alcoholics  by  permanent  segregation,  as  we  do 
the  feeble-minded,  there  would  be  something  to  be  said 
for  it,  but  there  is  nothing  whatever  to  be  said  for  the 
present  method  of  treatment  by  a  series  of  thirty  or 
forty  sentences.  The  victim  tamely  goes  down  to  prison 
for  a  few  days  or  weeks,  then  comes  back  and  gets 
drunk  again.  It  is  a  great  waste  of  the  community's 
money  and  no  good  whatever  to  the  alcoholic.  There 
ought  to  be  a  clearing-house  for  the  whole  problem  of 
alcoholism,  in  which  the  student  of  psychology  would 
take  a  leading  part  in  what  is  mainly  a  psychological 
question  and  not  a  social  question,  nor  a  physical 
question  merely. 

The  relation  of  alcoholism  to  tobacco  is  an  important 
subject  and  one  on  which  it  is  very  hard  to  be  clear.  If 
a  man  is  trying  to  stop  alcoholism  and  is  also  a  smoker, 
we  may  be  perfectly  sure  that  he  won't  stop  alcoholism 
unless  he  also  stops  tobacco.  But  we  know  that  the  use 
or  even  the  abuse  of  tobacco  does  n't  always  lead  to 
alcoholism.  The  person  who  has  fallen  a  victim  to 
alcoholism  and  also  smokes  has  got  to  stop  both  if  he  is 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

going  to  stop  either.  Especially  the  periodic  drinker  is 
apt  to  be  a  person  who  smokes  and  smokes  until  he 
gets  his  nerves  on  edge  and  then  breaks  out  into  acute 
alcoholism.  I  have  never  seen  any  serious  cardiac 
effects  from  tobacco  in  no  matter  what  excess.  I  don't 
believe  in  such  a  thing  as  a  tobacco  heart.  I  don't  be- 
lieve there  are  any  demonstrably  permanent  ill  effects 
parallel  to  the  very  well-known  effects  of  alcohol. 

I  have  never  been  able  to  get  enthusiastic  in  the  anti- 
cigarette  crusades,  because  I  know  too  many  strong 
and  healthy  men  who  began  to  smoke  when  in  short 
trousers.  I  can't  feel  strongly  that  it  does  much  harm 
except  to  people  whose  powers  of  resistance  are  weak- 
ened, as  is  the  case  with  the  alcoholic. 

The  tobacco  problem,  then,  is  wholly  different  in  the 
alcoholic  from  what  it  is  in  the  non-alcoholic.  In  the 
normal  person  tobacco  in  excess  produces  a  certain 
amount  of  nervousness  and  irritability  and  throat  ca- 
tarrh, but  not  any  serious  disease.  But  in  the  alcoholic, 
tobacco  is  an  entering  wedge  which  is  very  serious. 

The  psychology  of  the  chronic  alcoholic  is  very  like 
the  psychology  of  the  general  paralysis  of  the  insane. 
In  a  general  way  it  is  loss  of  the  finer  points  of  discern- 
ment, self-control,  and  memory,  especially  of  memory. 
Memory  suffers  from  alcoholism  more  than  any  other 
single  faculty. 

The  treatment  of  alcoholism,  in  those  who  are  not 
insane  or  feeble-minded,  is  the  only  branch  of  the  sub- 
ject that  I  shall  deal  with  here.  The  alcoholic,  who  has 

418 


POISONS 

no  mental  disease  or  defect  back  of  his  trouble,  is 
helped,  so  far  as  he  is  helped  at  all,  by  getting  at  the 
reason  why  he  started  drinking  and  has  continued  to 
drink.  Then  if  possible  we  try  to  find  a  stronger  mo- 
tive, a  motive  stronger  than  the  thing  that  has  driven 
him  to  drink,  and  thus  to  drive  him  out  of  drink. 

I  once  treated  a  woman  for  alcoholism  who  had  been 
at  it  for  twenty  years  and  who  had  been  through  the 
hands  of  all  sorts  of  physicians  and  psychologists, 
heads  of  sanatoria,  etc.  But  all  the  treatment  she  had 
received  up  to  the  time  I  first  saw  her  had  been  repres- 
sive. She  was  sent  into  the  country  and  put  in  a  sana- 
torium where  she  could  n't  get  alcohol  from  the  nurses, 
but  being  a  person  of  considerable  fascinations,  she 
wielded  them  over  the  doctors  and  nurses  and  in  the 
end  always  got  the  stuff.  She  was  entirely  defiant 
when  I  was  first  asked  to  take  care  of  her;  did  n't  take 
any  interest  in  the  idea  of  being  cured.  That  is  one  of 
the  very  hardest  types  of  person  to  cure.  I  suppose  the 
only  reason  that  I  got  any  grip  on  her  was  that  I  took 
instinctively  a  tack  opposite  to  all  previous  attempts. 
She  was  one  of  the  rich  people  who  do  not  know  how 
to  spend  their  money  and  she  was  rather  amused  by 
my  tactics.  Nothing  was  said  to  her  about  alcoholism. 
I  simply  tried  to  find  out  what  her  greatest  interest 
was.  Her  salvation  was  that  she  had  another  very 
great  interest  besides  alcohol.  She  had  a  very  real 
interest  in  a  certain  subject  which  I  won't  mention 
lest  she  might  be  recognized.  This  she  had  had  for 

419 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

years,  although  it  had  all  been  driven  out  by  drinking. 
I  succeeded  in  getting  her  in  touch  with  other  people 
who  were  equally  interested  in  that  subject.  I  suc- 
ceeded in  placing  responsibility  on  her  and  that  was 
practically  all  I  ever  did.  She  had  posed  as  an  intel- 
lectual invalid.  I  told  her  that  she  had  very  little 
brains,  but  had  very  real  capacity  in  another  direction. 

It  is  now  five  years  since  she  has  had  anything  to 
drink.  She  has  no  desire  for  it,  wholly,  I  think,  because 
she  has  so  much  interest  in  something  else.  The  idea 
does  n't  come  into  her  mind.  She  was  bored  to  death, 
and  the  technique  of  outwitting  her  doctors  and  nurses 
was  so  interesting  to  her  that  until  a  competing  interest 
came  on  the  scene  she  saw  no  special  reason  for  devot- 
ing her  energies  to  anything  else. 

I  have  worked  with  many  other  alcoholics  to  whom 
I  did  no  good  whatever  because  I  could  n't  discover  or 
create  an  interest.  I  don't  believe  any  one  has  suc- 
ceeded with  a  chronic  alcoholic  who  has  n't  had  the 
good  luck  to  create  an  interest.  With  a  certain  group 
of  alcoholics  the  trump  card  is  to  make  them  feel  that 
somebody  cares.  They  have  tired  out  the  patience  of 
those  who  naturally  would  care,  but  if,  in  spite  of  that, 
they  discover  that  somebody  else  does,  it  may  make  it 
worth  while  to  try  again  and  make  a  good  fight.  There 
are  people  who  don't  care  enough  about  their  own  lives 
to  think  it  worth  while  to  keep  them  going.  But  they 
may  suddenly  begin  to  take  an  interest  in  their  own 
lives  because  somebody  else  does.  But  it  has  to  be  a  real 

420 


caring  and  not  a  vague  or  professional  caring.  It  can't 
be  the  sort  of  friendship  that  we  make  by  the  dozen  a 
week.  In  the  second  edition  before  the  last  of  the 
"Boston  Directory  of  Charities,"  a  certain  Boston 
charity  advertised  to  supply  "friendship  to  all  ages 
and  both  sexes."  That  sort  of  friendship,  one  which 
you  can  furnish  wholesale,  does  n't  help  the  alcoholic. 
That 's  the  sort  of  "friendship"  which  is  given  for  the 
sake  of  the  other  person.  The  only  sort  of  friendship  of 
any  use  to  us  is  the  mutual  one,  and  that  comes  in 
some  miraculous  way  without  any  pious  "reason." 

Many  an  alcoholic  has  certain  times  in  the  day  which 
are  dangerous  ones.  He  feels  them  approaching,  he  is 
powerless  to  fight  them,  and  feels  as  a  person  might  in 
the  undertow  of  a  big  wave.  If  he  is  on  such  terms  with 
somebody  that  he  can  telephone  at  once  and  say  a  few 
words  that  mean  a  great  deal,  and  if  then  that  some- 
body will  turn  up  and  stay  with  him  for  a  few  hours,  it 
will  sometimes  tide  him  over  a  period  that  nothing  else 
on  earth  will  get  him  by  without  drink.  There  are  a 
good  many  people  who  have  gone  to  such  an  alcoholic 
at  such  times  every  month  or  so  for  years  until  he  has 
found  his  own  strength. 

Another  danger  to  the  alcoholic  is  extreme  mental  or 
physical  fatigue.  Extreme  fatigue  sometimes  means 
the  let-down  of  moral  restraint;  it  is  dangerous  for 
certain  people  to  get  tired  out. 

The  alcoholic  is  very  slow  to  believe  that  one  glass  of 
whatever  is  his  favorite  drink  is  to  him  fatal,  not  be- 

421 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

cause  of  its  immediate  effects,  but  because  it  puts  him 
on  an  inclined  plane  down  which  he  will  run  like  a 
heavy  body.  The  ordinary  individual  can  take  one 
glass  and  not  be  any  the  worse  for  it  in  any  capacity. 
The  alcoholic  is  the  one  who  can't  take  one  glass  with- 
out losing  his  control. 

The  process  of  helping  an  alcoholic  is  as  diversified 
as  that  of  helping  any  other  sort  of  people.  It  may  be 
he  has  the  wrong  job.  Change  of  work  may  then  be  the 
key  to  the  situation.  That  was  the  key  to  the  situation 
in  the  case  of  the  woman  whose  story  I  have  told  in  the 
beginning.  She  changed  her  job.  Occasionally  alcohol- 
ics have  started  drinking  because  they  have  no  satis- 
factory fun,  no  real  recreation.  More  often  than  either 
of  those,  I  think  it  is  because  they  feel  that  they  have 
no  friends  or  that  their  friends  don't  amount  to  any- 
thing. A  great  many  alcoholics  are  cured  by  Chris- 
tian Science,  which  is  an  example  of  the  influence  of 
religion  of  a  certain  type  on  the  alcoholic.  There  are 
many  others,  for  the  religious  motive  once  obtained 
is  the  most  powerful  destroyer  of  bad  habits  that  is 
known. 

Aside  from  these  personal  and  psychological  at- 
tempts to  help,  there  is  something  that  can  be  done  on 
the  physical  side,  not  for  the  alcoholic  who  drinks  once 
in  a  while,  but  for  the  alcoholic  who  is  in  the  clutches 
of  the  drug  and  can't  get  time  to  turn  around.  For  the 
one  who  is  so  befogged,  there  is  good  in  going  to  an  in- 
stitution and  getting  the  poison  wholly  out  of  his  sys- 

422 


,  POISONS 

tern.  That  does  n't  in  the  least  cure  him.  It  does  n't 
in  the  least  prevent  him  from  going  back  to  alcoholism. 
It  simply  gets  him  in  such  a  condition  of  mind  and 
body  that  he  really  can  be  appealed  to  by  his  own  best 
self  or  the  personality  of  some  one  outside.  If  any  maa 
has  been  up  continuously  for  three  nights  and  has  had 
no  sleep,  he  is  in  rather  a  poor  state  to  receive  a  moral 
appeal,  whether  from  within  or  from  without.  Hence 
the  best  thing  one  could  do  first  would  be  to  give  him 
a  good  chance  to  sleep.  So  the  alcoholic  who  has  been 
drinking  steadily  for  some  time  does  n't  really  catch 
anything  said  to  him  and  does  n't  hear  his  own  con- 
science. All  that  any  treatment  that  I've  ever  seen 
can  do,  is  to  put  the  individual  into  such  physical 
condition  that  he  has  a  fair  show  to  hear  the  voice  of 
his  own  conscience  or  of  any  appeal  from  outside.  But 
this  is  well  worth  while. 

I  suppose  most  of  you  know  that  the  various  patent 
medicines  serve  in  some  places  the  same  purpose  as 
alcohol.  Lydia  Pinkham's  Vegetable  Compound  and 
Hostetter's  Iron  Bitters  have  about  the  same  amount 
of  alcohol  as  alcoholic  stimulants,  and  are  more  expen- 
sive. One  of  the  cases  I  've  last  treated  got  drunk  on 
aromatic  spirits  of  ammonia.  We  may  not  be  able  to 
buy  whiskey  at  the  apothecary's  in  a  "dry"  town. 
Aromatic  spirits  of  ammonia  are  about  twice  as  strong 
as  whiskey. 

Dr.  Neff,  of  the  Massachusetts  Sanatorium  for  Al- 
coholics, likes  to  speak  of  the  whole  matter  of  alcohol- 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

ism  in  the  same  terms  as  he  uses  in  phthisis.  We  can 
cure  incipient  cases,  he  says;  not  the  advanced  chronic 
cases.  There  is  a  great  deal  in  it,  although  I  think  a 
psychological  classification,  more  like  Dr.  Anderson's, 
is  still  more  significant. 

Opium  and  its  Derivatives — Morphine ,  Heroin .  Eighty 
per  cent  of  the  people  who  have  the  morphine  habit 
in  this  country  have  acquired  it  from  doctors.  So 
Dr.  Alexander  Lambert  states  in  "Osier's  Modern 
Medicine."  Eighty  per  cent  acquired  it  because  of 
drugs  given  them  by  physicians.  I  think,  on  the  whole, 
the  greatest  single  evil  I  know  in  medicine  is  the  abuse 
of  opium  and  morphine.  It  is  a  tremendous  temptation 
to  a  doctor.  People  want  relief.  They  want  it  right 
off,  and  a  man  who  is  trying  to  make  a  living  and  keep 
the  good-will  of  his  patients  may  find  it  almost  impos- 
sible to  go  away  and  give  no  drug  as  an  immediate 
relief.  In  the  Massachusetts  General  Hospital  or  in 
any  place  where  one  does  medically  only  what  one  be- 
lieves ought  to  be  done,  I  suppose  not  one  person  in  a 
hundred  gets  any  morphine  at  all,  and  not  one  in  ten 
thousand  gets  it  more  than  ten  days.  Any  one  who  gets 
it  for  ten  days  is  in  danger  of  contracting  the  habit. 
If  we  ever  hear  of  any  one  taking  morphine  for  more 
than  ten  days,  that  person  is  in  need  of  our  help  or 
some  one  else's  help.  Sometimes  the  habit  is  acquired 
perfectly  accidentally.  The  doctor  meant  that  the 
drug  should  be  discontinued,  but  it  is  not  discontin- 

424 


POISONS 

ued.  Ten  days  is  enough  to  form  a  "set"  of  the  tissues 
which  demands  the  drug. 

The  most  important  thing  that  any  one  can  realize 
about  this  problem  of  morphine  is  that  after  it  is  taken 
for  a  little  while  it  causes  pain.  Of  course  it  is  taken 
at  first  to  relieve  pain,  but  after  we  have  been  taking  it 
a  little  while,  it  produces  pain  which  then  it  relieves. 
The  great  importance  of  that  point  is  this :  many  a  per- 
son feels  he  can't  stop,  can't  face  the  terror  of  the  pain 
for  which  originally  he  took  it.  But  often  it  is  true  that 
we  can  stop  morphine  and  the  pain  at  the  same  time. 

A  physician  came  to  me  two  years  ago  with  tabes 
dorsalis  and  the  lightning  pains  of  that  disease,  for  the 
relief  of  which  he  had  contracted  morphinism.  He  had 
often  thought  of  giving  up  the  morphine,  but  had  al- 
ways said  to  himself  that  he  knew  without  the  mor- 
phine he  could  n't  stand  the  pains  of  his  tabes  dorsalis 
and  had  rather  die  than  try.  He  had  never  heard  what 
I  have  just  explained,  that  morphine  can  produce  pain 
on  its  own  account.  He  had  been  out  of  practice  for  a 
good  while.  He  thought  every  one  looked  down  upon 
him,  that  no  one  could  help  getting  some  notion  of 
what  he  had  and  despising  him  for  the  syphilis  back  of 
it.  I  told  him  his  pain  might  leave  him  if  he  quit  mor- 
phine and  took  the  Towns  treatment.  He  has  never 
had  any  pain  from  that  time  —  two  years  ago  —  to 
this.  He  found  that  much  of  the  trouble  which  he  had 
in  his  back  and  legs  (weakness  and  staggering)  was  the 
result  of  the  drug  and  not  of  his  tabes.  There  is  no 

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more  pain  coming  to  him  because  of  his  tabes ;  he  was 
keeping  up  the  pain  by  the  very  thing  he  thought  re- 
lieved it.  He  could  walk  straight  and  stand  up  straight 
without  pain,  when  once  he  quit  his  morphine.  He 
found  that  he  could  get  back  into  medical  practice,  got 
some  self-respect,  and  within  a  year  he  was  all  right. 
He  had  a  good  inheritance.  He  was  not  a  degenerate 
in  any  sense. 

I  said  eighty  per  cent  of  the  cases  known  to  Dr. 
Lambert  were  due  to  the  opium  given  as  prescriptions 
by  physicians.  A  considerable  portion  of  the  remaining 
twenty  per  cent  are  doctors  themselves.  The  profes- 
sion which  figures  most  numerously  in  the  list  of  occu- 
pations of  those  who  get  morphinism  is  the  medical 
profession.  If  anybody  thinks  that  fear  and  knowledge 
ever  kept  anybody  straight  sexually,  he  had  better 
consider  this  fact.  Who  knows  best  the  dangers  of 
morphinism?  Why,  of  course,  it  is  the  doctor.  And 
who  gets  it  oftenest?  The  doctor.  Long  ago  I  made 
up  my  mind  that  knowledge  did  not  keep  anybody 
straight  in  matters  of  sex,  in  matters  of  hygiene,  or  in 
avoiding  a  habit  like  morphinism. 

In  this  country  practically  nobody  gets  those  beau- 
tiful dreams  we  read  about  in  De  Quincey's  "Con- 
fessions of  an  Opium-Eater."  Morphine  is  taken,  not 
to  bring  about  a  beautiful  state  of  mind,  but  to  get 
some  one  out  of  a  hellish  state  of  mind.  It  is  not  for 
pleasure  that  it  is  taken,  but  to  relieve  discomfort.  De 
Quincey  took  laudanum,  which  nobody  takes  nowa- 

426 


POISONS 

days.  Laudanum  is  an  alcoholic  extract  of  opium. 
Chinamen  always  smoke  opium;  but  white  people  al- 
most never  smoke  it.  Perhaps  this  difference  in  the 
way  the  drug  is  taken  explains  why  Chinamen  take  it 
for  pleasure,  while  Americans  take  it,  never  for  pleas- 
ure, always  for  relief. 

I  have  said  that  opium  or  any  of  its  preparations 
taken  more  than  ten  days  is  a  danger ;  sometimes  it  is  a 
risk  that  we  must  take  or  a  necessary  evil.  A  person 
with  a  perfectly  hopeless  cancer  which  can't  be  oper- 
ated on,  and  which  is  torturing  the  patient,  rightly 
takes  opium  if  the  doctor  feels  perfectly  sure  that  the 
man  is  near  the  end  of  life.  However,  one  must  be 
absolutely  sure  of  the  diagnosis  before  he  takes  such  a 
responsibility  of  making  a  morphinist  of  a  patient. 

I  once  went  to  see  a  lady  supposed  to  be  dying  of 
cancer  of  the  stomach.  But  like  Charles  the  Second, 
she  seemed  to  be  taking  an  unconscionably  long  time 
about  dying,  and  her  friends  began  to  wonder  why  she 
did  n't  "get  well  or  something."  She  had  a  tumor,  a 
lump  in  the  region  of  the  stomach,  which  lump,  coming 
as  it  did  at  the  age  of  seventy  with  severe  stomach 
symptoms,  caused  the  doctor  very  naturally  to  make 
the  diagnosis  of  cancer  of  the  stomach.  Then  the  lump 
began  to  disappear  and  by  the  time  I  got  there,  there 
was  no  lump.  The  question  arose  as  to  what  else  be- 
sides morphinism  she  then  had,  and  in  my  best  judg- 
ment she  had  nothing  else.  The  doctor  was  not  at  all 
ready  to  explain  that  to  the  family.  It  did  n't  look 

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particularly  well  for  him.  He  had  been  helping  the 
old  lady  in  a  pleasant  way  into  the  next  world,  but  she 
showed  no  special  tendency  to  take  that  step.  I  told 
him  that  either  he  or  I  must  tell  the  family  what  the 
situation  was.  He  asked  me  to  tell  them.  The  old  lady 
got  well.  It  is  all  right,  then,  to  be  humane  and  ease 
our  patients  into  the  next  world,  provided  we  are  quite 
sure  that  their  time  has  come. 

The  morphine  situation  in  this  country  has  changed 
a  good  deal  in  the  past  year  and  a  half,  owing  to  the 
passage  of  the  Harrison  Law.  It  seems  to  me  to  be 
doing  some  real  good.  The  law  does  n't  forbid  any- 
body to  take  morphine.  It  merely  makes  it  necessary 
that  a  physician  who  prescribes  morphine,  opium,  or 
heroin  should  do  it  in  such  a  way  that  the  United 
States  Government  knows  who  is  doing  it,  and  how 
much  each  doctor  in  the  country  is  giving.  Prescrip- 
tions are  written  on  a  special  blank  supplied  to  us,  and 
as  each  of  us  has  a  particular  number  that  no  other 
doctor  has,  that  number  has  to  be  put  on  the  blank, 
whereby  we  can  be  identified,  so  that  the  United 
States  Government,  if  it  chooses  to  take  the  trouble, 
can  find  out  what  doctors  are  giving  morphine,  and 
if  they  are  giving  more  than  they  should.  Without 
prescriptions  on  those  official  blanks  one  cannot  get 
morphine  to-day  unless  the  law  is  broken,  and  the 
apothecary  is  distinctly  afraid  to  break  the  law.  It  is 
certainly  more  difficult  to  get  morphine  contrary  to 
law  to-day  than  it  has  ever  been  before. 

428 


POISONS 

Acute  poisoning  occurs  as  a  rule  only  in  young  people 
who  take  morphine  with  suicidal  intent.  Four  grains 
will  ordinarily  kill.  But  in  a  person  who  is  used  to  it 
^orty  grains  may  produce  no  effect  whatever.  Ordinary 
medical  doses  are  one  fourth  of  a  grain  or  less.  The 
acute  cases  are  characterized  by  more  or  less  profound 
sleep  with  contracted  pupils  and  extraordinarily  slow 
breathing.  Most  of  us  breathe  about  eighteen  times  a 
minute;  the  person  in  coma  from  morphine  breathes 
five,  six,  or  seven  times  a  minute,  and  this  with  the 
"pin-point  pupil"  of  the  eye,  very  much  contracted, 
is  generally  enough  for  diagnosis.  Part  of  the  morphine 
is  excreted  in  the  stomach.  Hence  part  of  the  treat- 
ment is  to  keep  washing  out  the  stomach  again  and 
again.  If  we  don't  do  that,  the  drug  is  reabsorbed  in  the 
stomach  and  the  person  keeps  it  in  his  system.  If  we 
can  keep  a  person  alive  for  eight  hours  in  acute  mor- 
phine poisoning,  the  poison  is  usually  excreted  through 
the  bowel  and  kidney.  So  our  problem  is  to  keep  him 
alive  for  that  period  of  time.  The  treatment  simulates 
cruelty.  We  must  make  the  patient  sufficiently  un- 
comfortable to  keep  him  awake  if  possible.  I  have 
walked  people  sometimes  up  and  down  for  hours  in  the 
night  to  prevent  them  from  lapsing  off  into  this  sleep. 
We  have  no  antidotes  which  accomplish  much.  The 
best  antidote  is  pain ;  that  we  apply. 

Persons  with  chronic  morphine  habit  may  be  sus- 
pected of  it  (i)  because  they  do  not  keep  their  morning 
engagements.  They  almost  never  have  good  nights 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

and  as  a  consequence  do  not  get  started  in  the  morning. 
Hence  to  the  best  of  their  ability  they  never  make  any 
morning  engagements,  and  if  they  do  are  always  very 
late.  The  reason  I  first  suspected  a  doctor,  later  proved  a 
morphinist,  was  this.  He  called  me  in  consultation  and 
I  reached  his  town  at  nine  o'clock.  He  was  n't  there  to 
meet  me,  and  I  stayed  at  the  station  until  nearly  ten 
o'clock  when  he  turned  up.  This  is  the  sort  of  thing 
people  do  in  the  comparatively  early  stages  of  the 
trouble.  (2)  In  others  we  may  notice  that  the  quality 
of  the  voice  in  the  early  morning  is  inexplicably  hoarse, 
and  this  may  well  be  due  to  morphine.  (3)  They  are 
generally  notably  pale  and  notably  thin.  (4)  They  are 
very  capricious,  subject  to  extraordinary  ups  and 
downs  of  temperament.  None  of  these  symptoms  are 
always  seen  or  are  in  any  way  reliable  in  diagnosis. 
We  probably  all  of  us  know  morphinists  whom  we  have 
never  recognized.  None  the  less  the  symptoms  given 
are  of  value  as  pointers. 

As  to  the  cure,  the  first  thing  to  be  said  is  that  no- 
body is  ever  cured  at  home.  It  is  dangerous  to  make  a 
sweeping  remark  like  that,  but  certainly  it  is  the  rarest 
thing  in  the  world  to  be  cured  at  home.  The  patient 
can  get  the  dose  of  morphine  down  from  ten  to  five 
grains  and  then  to  three  a  day,  possibly  lower;  but  at 
some  point  he  always  sticks.  It  is  perfectly  easy  to  cut 
it  down  to  within  a  grain  or  two  of  zero  and  practically 
impossible  to  get  beyond  that  point.  If  the  doctor  tries 
to  treat  a  patient  in  his  own  home,  there  is  always  some 

430 


POISONS 

concealed  supply  of  the  drug  which  he  cannot  find. 
Hence  there  is  no  satisfactory  treatment  of  morphin- 
ism without  institutional  control,  where  the  first  thing 
to  be  done  to  a  patient  is  to  have  him  stripped  and 
given  a  bath.  During  this  his  clothes  are  thoroughly 
searched  and  all  the  belongings  gone  through.  No  mor- 
phinist  can  be  trusted  to  speak  the  truth  about  his 
morphine. 

To  take  the  drug  away  without  doing  anything  else 
to  counteract  the  effects  of  withdrawal  is  to  subject 
the  person  to  the  most  horrible  torture  that  I  know. 
I  Ve  done  it  a  number  of  times  before  any  better  treat- 
ment was  known,  and  I  think  it  causes  the  most  awful 
suffering  I've  ever  seen,  suffering  which  lasts  weeks, 
not  merely  days.  There  are  a  great  many  institutions 
and  a  great  many  so-called  cures  for  morphinism,  but 
practically  all  of  them  are  fakes.  Practically  all  of  the 
11 cures"  contain  the  very  thing  they  say  they  are  tak- 
ing away  and  a  good  many  of  them  are  run  by  physi- 
cians who  take  morphine  themselves.  The  greatest 
scandal  in  medicine  is  the  existence  of  the  institutions 
of  this  kind.  There  may  be  others  besides  the  two 
which  I  know  to  be  honest.  These  are  the  C.  B.  Towns 
Hospital  in  New  York  and  a  similar  hospital  in  Brook- 
line,  Massachusetts.  The  Towns  treatment  was  gotten 
up  and  used  by  a  layman,  not  a  doctor.  After  he  had 
made  a  competence  he  decided  that  he  would  like  to 
serve  the  public.  He  gave  the  formula  for  the  treat- 
ment to  Dr.  Alexander  Lambert,  and  he  published  it 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

in  all  its  details  in  the  Journal  of  the  American  Medical 
Association.1  Dr.  Lambert  did  nothing  but  carry  out 
what  Mr.  Towns  taught  him.  I  have  sent  a  good  many 
people  to  the  hospitals  where  the  Towns-Lambert 
treatment  is  given  in  New  York  and  in  Brookline.  It 
has  worked  a  cure  and  a  permanent  cure.  I  have  sent 
people  there  who  had  the  habit  for  many  years  and 
who  have  n't  taken  any  morphine  since. 

I  am  not  at  all  enthusiastic  about  the  same  treat- 
ment for  alcoholism.  It  is  not  much  torture  to  stop 
alcoholism,  and  when  we  once  have  stopped,  it  is  com- 
paratively easy  to  go  back  to  it.  But  with  morphine 
it  is  torture  to  stop  and  comparatively  easy  to  stay 
"stopped."  The  whole  benefit  of  the  Towns  treatment 
is  to  make  it  possible  for  people  to  stop  morphine  with- 
out great  torture.  Whatever  suffering  there  is  is  over 
in  two  days,  and  there  is  not  much  even  in  those  two 
days.  The  essentials  are  purgation  and  belladonna. 
The  latter  is  given  every  hour,  day  and  night,  for  the 
first  twenty  or  twenty-two  hours,  and  during  that 
time  we  give  doses  of  purgatives  that  are  a  scandal. 
Mr.  Towns  is  a  man  of  very  striking  speech  though  his 
metaphors  are  not  always  elegant.  "If  you  want  to 
give  purgatives  to  a  drug  fiend,"  he  says,  "measure 
out  a  dose  for  an  elephant,  and  then  double  it."  That 
is  about  the  way  we  give  it  and  it  works  tremendously 
well.  Towns  himself  is  one  of  the  most  forcible  per- 

1  Journal  of  the  American  Medical  Association,  Sept.  25,  1909,  and 
Feb.  18,  1911. 

432 


POISONS 

sonalities  I  ever  knew.  When  I  first  heard  about  the 
treatment,  I  thought  his  personality  was  a  large  part 
of  it.  But  since  then  the  same  treatment  has  been  es- 
tablished here  in  Brookline  under  ordinary  conditions 
and  without  Mr.  Towns,  yet  it  works  just  as  well.  I 
think  it  is  a  great  boon  to  humanity.  The  weak  point 
of  it  is  that  it  costs  so  much.  It  is  not  at  all  expensive 
as  far  as  the  medicine  is  concerned,  but  as  administered 
in  institutions  to-day  with  paid  doctors  and  nurses,  it 
is  a  very  expensive  proposition.  The  cost  of  the  Towns 
treatment  averages  about  one  hundred  dollars.  Some 
pay  more:  a  few  pay  less.  It  is  a  lump  sum  for  what- 
ever time  they  stay.  They  don't  pay  by  the  week, 
which  is  a  great  advantage.  The  average  stay  is  ten 
days.  The  last  eight  days  are  merely  spent  in  getting 
toned  up  generally  and  not  in  having  any  special 
treatment.  The  drug  is  all  gotten  rid  of  in  the  first 
two  days.  We  sent  doctors  on  to  New  York  to  learn 
the  tricks  of  the  trade,  as  Mr.  Towns  himself  knows 
much  more  about  it  than  any  doctor  does. 

Degenerates,  prostitutes,  or  criminals  who  turn  up 
in  prison  or  in  the  slums  with  these  habits,  are  not  to 
be  helped  much  by  any  cure.  They  have  no  sound 
stamina  of  character  and  no  interest  to  hold  them  after 
they  have  been  cured. 

The  cocaine  habit  is  comparatively  rare.  There  are 
very  few  cases  except  those  complicating  morphine  and 
alcohol.  The  habit  is  generally  due  to  low-grade  men- 
tality. Cocaine  is  used  very  commonly  by  prostitutes 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

and  those  of  the  jail  type.  It  is  generally  taken  as  snuff 
or  as  a  nasal  spray.  One  wants  to  be  always  on  one's 
guard  against  sprays  and  other  throat  and  nose  reme- 
dies which  relieve  very  markedly  and  at  once.  They 
generally  contain  cocaine,  and  are  always  dangerous 
for  that  reason. 


CHAPTER  XVII 

INDUSTRIAL  DISEASES  —  SKIN   DISEASES 

I  HAVE  a  little  more  to  say  about  industrial  diseases 
before  I  finish  that  subject  and  go  on  to  skin  diseases. 
The  first  thing  I  want  to  say  about  it  is  that  if  gives 
rise  to  more  examples  of  the  fallacy  expressed  by  the 
Latin  words,  "Post  hoc,  ergo  propter  hoc1'  ("After  this, 
therefore  because  of  this"),  than  any  other  experience 
that  comes  to  physicians. 

A  man  in  a  hurry  dipd  once.  He  was  in  a  hurry  and 
then  he  died.  The  fallacious  inference  is  that  he  died 
because  he  was  in  a  hurry.  The  more  we  think  of  this, 
the  more  we  see  all  around  us  the  disasters  that  happen 
because  persons  can't  reason  straight.  It  is  the  duty  of 
every  physician  and  every  one  who  associates  himself 
with  physicians  to  do  his  or  her  part  of  the  enormous 
job  of  straightening  out  the  world  in  relation  to  that 
fallacy.  It  occurs  in  every  department  of  life  and 
causes  disasters  in  every  department  of  life. 

In  industrial  diseases  fallacies  of  that  kind  are  es- 
pecially numerous.  Mr.  So-and-So  lifted  a  heavy 
weight ;  the  next  day  he  noticed  that  he  had  a  chill  and 
the  doctor  said  he  had  pneumonia.  Therefore  (the 
false  reasoning  persuades  us)  the  lifting  of  the  heavy 
weight  caused  his  pneumonia.  The  human  mind  de- 
mands a  cause  for  everything  and  we  respect  the  hu- 

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A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

man  mind  for  this.  But  unfortunately  there  are  not 
known  causes  enough  to  go  around.  You  have  had  a 
chill,  you  have  had  fever,  and  why?  The  Lord  only 
knows.  The  doctor  can  find  no  disease.  But  mean- 
time you  demand  a  cause.  You  know  that  you  got 
your  feet  wet,  so  you  say  the  chances  are  that  this 
caused  the  chill. 

A  man  called  me  up  once,  out  of  a  well-deserved 
sleep  about  three  in  the  morning,  to  come  to  his  house 
as  fast  as  I  could.  I  had  not  learned  then  that  hurry 
calls  rarely  deserve  to  be  attended  to  at  once.  I  found 
a  patient  in  bed  and  in  great  agitation.  He  said  that 
the  afternoon  before  he  had  tried  to  fix  some  curtains 
and  had  climbed  up  on  a  chair.  His  wife  had  wanted 
him  to  fix  those  curtains  for  a  long  time.  He  did  n't 
realize  at  the  time  that  it  did  him  any  harm,  but  a  few 
hours  ago  when  he  went  to  bed  he  found  a  tumor  right 
on  his  breast  bone.  Then  he  remembered  that,  when 
trying  to  put  those  confounded  curtains  up,  he  slipped 
and  came  right  down  on  his  chest.  He  thought  the 
lump  on  his  breast  bone  had  grown  in  the  hours  since 
he  had  noticed  it,  and  he  could  n't  stand  it  any  longer 
without  knowing  what  it  was.  I  found  that  it  was  a 
perfectly  natural  part  of  his  skeleton.  He  was  born 
with  it  and  would  have  it  to  the  day  he  died,  but  he 
was  quite  sure  that  that  thing  was  n't  there  when  he 
went  to  bed  the  night  before.  He  was  perfectly  willing 
to  swear  that  it  was  n't  there,  whereas  I  was  perfectly 
willing  to  swear  that  it  always  had  been  there  and  al- 

436 


INDUSTRIAL   DISEASES 

ways  would  be  there.  This  illustrates  two  things:  the 
fallibility  of  human  testimony  in  general  and  the  neces- 
sity of  finding  at  once  some  cause,  even  a  false  cause, 
for  everything.  When  one  finds  something  the  matter 
with  him,  one  goes  back  to  the  nearest  event  that  is 
blameworthy  according  to  the  popular  current  notions. 
The  nearest  blameworthy  event  is,  perhaps,  that  one 
fell  down,  or  lifted  something,  or  that  one  got  cold,  or 
one  got  one's  feet  wet.  Hence  it  is  that  events  of  this 
sort  get  hitched  up  in  the  popular  mind  with  so  many 
diseases  really  quite  independent  of  any  such  cause. 

Most  people  who  get  sick  have  to  work,  arid  when 
they  are  looking  for  the  causes  of  their  sickness  it  is 
getting  to  be  more  and  more  the  custom  to  blame  one's 
work.  This  is  true  especially  the  more  one  hears  of 
"industrial  diseases,"  of  workmen's  compensation, 
etc.  This  habit  leads  to  a  great  number  of  mistakes 
and  makes  it  difficult  at  the  present  time  to  know  what 
are  industrial  diseases  and  what  are  not. 

Take  the  most  familiar  of  all  the  puzzles.  A  man 
has  tuberculosis.  He  has  worked  in  a  dusty  place.  Did 
the  dust  cause  the  tuberculosis?  It  is  very  easy  to  say, 
"Post  hoc,  ergo  propter  hoc'1;  the  tuberculosis  resulted 
from  working  in  a  dusty  place.  But,  in  fact,  the  relation 
of  tuberculosis  to  dust  is  a  difficult  and  complicated 
matter.  There  are  a  few  facts  which  we  know  about 
it  and  a  great  many  that  we  don't  know  at  all. 

In  the  first  place,  we  must  distinguish  the  kinds  of 
dust  in  their  relation  to  disease.  There  is  a  kind  of  dust 

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A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

which  is  good  for  tuberculosis.  That  is  one  of  the  few 
things  we  know.  Coal  dust,  such  as  the  miner  gets  in 
the  mines,  we  all  inhale  to  a  certain  extent  in  the  cities, 
whereby  our  lungs  get  to  be  a  handsome  dark  gray  in- 
stead of  a  light  pink.  But  miners,  who  inhale  the  most 
of  it,  very  seldom  die  of  tuberculosis.  There  is  a  rea- 
son for  this.  The  coal  dust  makes  in  the  lung  minute 
scars,  so  small  that  they  don't  injure  it  to  any  extent, 
but  big  enough  to  wall  in  the  tubercle  bacilli,  which  are 
present  in  almost  all  of  us  sooner  or  later. 

Coal  dust  and  smoke  carbon,  then,  are  good  for  tu- 
berculosis. But  stone  dust  and  metal  dust  are  bad  for 
tuberculosis.  Stonecutters,  especially  those  who  work 
indoors  where  the  dust  is  n't  blown  away,  have  a  very 
much  higher  rate  of  tuberculosis  than  other  men  of  the 
same  wage  and  same  social  conditions.1  I  add,  "the 
same  wage  and  same  social  conditions,"  because  noth- 
ing makes  so  much  difference  in  tuberculosis  as  the 
low  wages.  The  low- wage  trades  have  the  most  tuber- 
culosis. An  occupation  in  which  there  is  abundant 
tuberculosis  is  that  of  the  laborer  outdoors.  That  is 
low-paid  work  and  goes  along  with  alcoholism  and 
poor  nutrition,  bad  housing,  etc.  Men  with  low  nutri- 


1  U.  S.  Census  Bureau,  Tuberculosis  in  the  United  States  (1908), 
gives  the  following  rates  per  100,000  of  population:  — 

Marble  and  stone  cutters 541 

Laborers 415 

Iron  and  steel  workers 251 

Textile  workers 213 

Journalists. 189 

Lawyers 144 

Miners 130 

438 


INDUSTRIAL   DISEASES 

tion  and  high  alcoholism  are  frequently  the  ones  who 
get  tuberculosis. 

The  metallic  dust  that  comes  off  scissors  in  the  pro- 
cess of  scissor- grinding,  or  conies  off  metal  while  it  is 
being  polished  at  the  emery-wheel,  is  certainly  dan- 
gerous to  the  lungs.  These  two  things  we  know:  that 
coal  dust  is  good  and  metal  dust  is  bad  for  the  lungs. 
But  that  is  about  the  limit  of  our  knowledge. 

We  don't  know  much  about  the  effects  of  the  dust 
that  we  have  in  textile  factories,  the  lint  particles,  the 
cotton  and  wool  dust  in  the  air.  People  who  are 
breathing  that  kind  of  dust  have  some  tuberculosis. 
But  the  question  is,  Does  this  dust  cause  the  disease, 
or  is  it  due  to  an  infection  from  person  to  person  or  to  a 
diminution  of  vital  resistance  from  some  cause  outside 
the  shop?  We  cannot  infer  that  merely  because  a 
person  has  a  dusty  trade  it  does  him  harm.  It  may 
have  no  bad  effects  whatever.  It  may  have  an  effect  on 
other  organs  besides  the  lungs.  We  don't  know  much 
about  it  in  other  organs  except  that  it  causes  in  the 
throat  and  nose  irritation  which  blocks  the  nose.  This 
anybody  who  works  in  dust  rightly  attributes  to  the 
dust.  But  irritation  of  the  throat  and  of  the  nose  are 
so  prevalent  and  on  the  whole  so  trivial  that  we  don't 
as  yet  do  much  about  them  as  industrial  diseases. 

One  of  the  few  well-known  industrial  diseases,  which 
has  recently  become  well  known  in  this  vicinity  owing 
to  the  tunnel  construction  in  South  Boston,  is  caisson 
disease.  Its  proper  name  is  "compressed  air  disease," 

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because  wherever  we  get  compressed  air  we  get  this 
disease,  whether  in  a  caisson  or  anywhere  else.  The 
caisson  is  an  enclosed  compartment  in  which  men 
work  under  water  when  constructing  a  tunnel  or 
bridge  pier  under  water.  In  a  caisson  men  work  in  air 
which  is  tremendously  compressed.  The  object  of 
compressing  the  air  is  to  make  it  help  to  hold  up  the 
walls  of  the  tunnel.  When  air  is  under  three  or  four 
times  the  ordinary  pressure,  it  plays  a  considerable 
part  in  holding  up  the  walls  of  a  tunnel  and  therefore 
makes  it  easier  to  build. 

But  a  man  working  under  those  conditions  is  subject 
to  danger,  provided  he  does  n't  take  a  great  deal  of 
time  in  getting  used  to  this  compressed  air  on  his  way 
into  the  caisson  and  also  in  getting  used  to  ordinary 
atmospherical  pressure  on  his  way  out. 

When  we  take  a  train  that  goes  through  a  tunnel 
swiftly,  as,  for  instance,  the  tunnel  of  the  Pennsylvania 
Railroad,  close  to  its  station  in  New  York,  we  are  apt 
to  feel  a  difference  in  the  air  pressure  on  our  ear  drums. 
When  a  train  rushes  into  a  tunnel  like  that  it  exerts  a 
certain  amount  of  suction,  acting  like  a  piston  in  a 
tube.  Hence  the  air  in  the  train  is  rarefied  for  a  time, 
and  we  feel  it  on  our  ear  drums.  If  we  swallow  once 
or  twice  and  so  force  into  the  Eustachian  tube,  and  so 
into  the  middle  ear,  the  same  air  that  there  is  outside, 
we  are  relieved. 

That  sort  of  thing  on  a  much  greater  scale  is  what 
the  workmen  go  through  every  time  they  go  into  the 

440 


'  INDUSTRIAL   DISEASES 

caisson  or  come  out  of  it.  If  one  does  it  gradually, 
taking  two  hours  or  so  in  the  process  of  going  in  and  in 
the  process  of  coming  out,  getting  used  to  each  suc- 
cessive pressure  by  waiting  twenty  minutes  in  one 
pressure  and  then  going  to  double  that  pressure,  there 
is  no  considerable  danger.  But  if  men  go  in  and  out 
rapidly,  as  it  is  ordinarily  done  in  most  tunnels  where 
there  is  not  very  active  medical  supervision,  they  are 
very  liable  to  serious  disease  and  quite  liable  to  death. 
There  are  always  fatalities.  There  have  been  a  num- 
ber of  cases  of  this  disease  in  the  Massachusetts  Gen- 
eral Hospital  since  the  South  Boston  tunnel  was  begun. 
The  commonest  lesion  that  we  see  is  rupture  of  the 
ear  drums;  that  has  happened  a  great  many  times  in 
this  tunnel.  As  they  come  out  of  the  tunnel  the  air  on 
the  inside  of  the  ear  drum  is  so  much  heavier  than  the 
air  outside  that  the  drum  is  pushed  out  and  broken. 
On  the  way  into  the  tunnel  the  conditions  are  reversed. 

Pains  in  various  parts  of  the  body  ("the  bends") 
occur  in  about  90  per  cent  of  all  cases.  They  vary  from 
mild  to  very  severe.  Vertigo  ("staggers")  occurs  in 
about  5  per  cent. 

More  serious  is  caisson  disease  of  the  spinal  cord, 
with  paralysis  and  death,  a  disease  entirely  prevent- 
able but  for  the  facts  of  human  nature.  We  know  ex- 
actly how  to  prevent  it,  but  the  difficulties  are  pretty 
equally  balanced  between  the  employer  and  the  em- 
ployee. No  matter  how  many  times  an  employee  has 
been  told  to  go  in  and  out  slowly,  he  is  sure  to  notice 

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that  some  of  his  fellows  have  gone  quickly  and  yet 
have  n't  got  the  disease.  Men  almost  always  want  to 
take  their  chances  of  disease  unless  they  are  forced  by 
law  to  go  as  slowly  as  I  have  indicated. 

There  are  regulations  in  England  whereby  it  takes 
about  two  hours  before  a  man  is  allowed  to  bear  the 
full  pressure  on  the  way  in  and  on  the  way  out. 
Neither  for  the  employer  nor  the  employee  is  it  a 
paying  process  to  care  for  health,  hence  regulations  are 
very  hard  to  enforce.  There  is  no  law  in  Massachusetts 
on  the  subject  that  I  know  of,  and  the  condition  of 
things  is  not  at  all  satisfactory  now. 

Conceivably  tunnels  could  be  built  without  com- 
pressed air  and  this  would  be  a  good  thing  for  the 
workmen ;  but  it  is  so  much  more  expensive  that  there 
is  no  prospect  that  they  will  be. 

The  treatment  of  compressed  air  disease  is  recompres- 
sion  by  means  of  the  usual  locks,  where  the  pressure 
is  raised  quickly  to  the  working  point.  This  gives  relief 
in  most  cases.  Slow  decompression  is  then  carried  out. 

Q.  Does  the  law  require  locks? 

A.  There  is  no  law  about  that  because  the  thing  would 
enforce  itself.  They  must  have  locks  in  order  to  keep  up  the 
pressure  on  the  inside,  to  keep  the  compressed  air  from  leak- 
ing out,  and,  on  the  other  hand,  to  enable  the  men  to  get 
along  at  all.  If  every  one  got  the  disease  every  time  he  vio- 
lated the  rules,  it  would  be  much  simpler  to  enforce  them. 
People  are  different  in  their  susceptibility  to  this  as  to  all 
diseases.  By  none  of  the  industrial  hazards  do  men  get 
caught  every  time,  so  they  usually  take  their  chances. 

442 


INDUSTRIAL  DISEASES 

Diseases  due  to  heat  and  cold  are  hard,  indeed,  to  say 
anything  definite  about.  People  get  used  to  working 
in  high  temperatures  and  they  get  used  to  working  in 
low  temperatures,  and  we  don't  know  enough  to  be 
sure  that  any  definite  disease  is  due  to  temperature 
except  in  extreme  cases.  Some  of  the  worst  hazards 
seem  to  be  in  cold-storage  plants,  where  men  go  very 
suddenly  from  hot  to  cold  temperatures  and  back 
again.  Even  there  we  cannot  give  a  name  to  any 
disease  or  symptoms  due  to  the  hazard.  There  is  a 
strain  upon  the  individual  presumably,  but  we  don't 
know. 

Muscular  strains  are  due  to  cramped  positions  or  to 
excessive  use  of  one  group  of  muscles.  This  is  also  very 
difficult,  indeed,  to  bring  under  any  occupational  dis- 
ease. It  is  not  the  people  who  lift  the  heaviest  weights 
who  get  the  strains.  It  is  the  people  who  for  some  rea- 
son or  other  are  not  equal  to  that  particular  weight, 
heavy  or  less  heavy.  We  can't  make  any  rule  in  this 
case  as  to  what  is  proper  and  what  is  not  proper.  It  is 
a  question  of  knack  in  the  way  the  muscles  are  used. 
Again,  it  is  very  hard  to  make  sure  what  condition  the 
man  was  in  when  he  underwent  a  certain  strain.  He 
may  have  been  in  a  condition  so  that  he  would  get  hurt 
whatever  he  picked  up. 

I  have  spoken  earlier  of  a  case  of  heart  disease  at- 
tributed to  lifting  one  corner  of  a  piano.  The  evidence 
was  convincing  to  me  that  the  man  had  the  heart  dis- 
ease before  he  went  into  this  job.  Even  if  he  had  been 

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sitting  still  in  a  chair  the  new  symptoms  might  have 
appeared  in  the  way  they  did  the  day  after  lifting  this 
weight.  We  do  not  know  whether  the  strain  did  it  or 
whether  it  was  a  mere  coincidence. 

Occupational  skin  diseases  are  generally  of  the  ec- 
zematous  type  and  affect  chiefly  the  hands  of  candy 
makers,  .bakers,  and  all  who  deal  with  sugar;  also 
masons  (lime  and  cement),  stonecutters,  and  all  who 
handle  irritating  drugs,  anilin  colors,  tar  or  paraffin. 

Change  of  occupation  is  advisable  in  all  severe  cases. 

There  is  a  similar  difficulty  about  the  occupational 
neuroses,  of  which  "writer's  cramp"  is  the  only  form 
popularly  known.  Writers  do  not  generally  get  it  from 
simple  over-use  of  the  hand  muscles,  and  it  is  n't  gen- 
erally known  how  they  get  it.  It  appears  in  all  sorts 
of  people,  including  some  who  do  very  little  writing. 
When  it  does  come  it  is  chiefly  pain  and  not  muscular 
cramp.  Another  example  is  "tennis  elbow"  and  "vio- 
lin elbow,"  which  are  terms  that  explain  themselves. 
Cigarmakers  get  occupational  neurosis  in  their  hands. 
A  certain  number  of  typewriters  get  it,  but  the  out- 
standing fact  is  that  the  people  who  use  their  muscles 
the  most  are  not  the  ones  who  get  these  neuroses. 
The  neurosis  generally  occurs  in  people  who  have  used 
their  hands  an  ordinary  amount  and  no  more  than 
hundreds  of  people  who  have  no  trouble  with  their  hands. 
There  is  something  else  in  the  person,  some  x  or 
"nervous  constitution,"  whereby  even  a  moderate 
amount  of  use  of  the  muscles  may  bring  about  this 

444 


INDUSTRIAL  DISEASES 

condition.  The  thing  that  makes  it  natural  to  believe 
that  the  muscular  work  is  itself  the  whole  cause  of  an 
occupational  neurosis  is  that  the  cessation  of  the  mus- 
cular work  generally  cures  the  trouble,  especially  the 
cessation  of  the  particular  act  one  has  been  doing.  A 
person  may  be  able  to  use  his  hand  quite  well  in  a 
different  way.  I  remember  a  person  who  could  n't 
write  at  all  without  great  pain  if  he  held  his  pen  in  the 
ordinary  way,  but  after  he  was  taught  to  keep  the  pen 
between  the  second  and  third  fingers,  so  that  he  did  not 
make  a  terrific  contraction  of  all  the  fingers  when  he 
wrote,  the  whole  thing  disappeared. 

As  a  rule  people  who  have  these  neuroses  are  found 
to  be  writing  with  their  shoulders  and  tongues  as  well 
as  with  their  fingers.  That  is  an  element  in  the  trouble, 
—  the  wrong  application  of  force  or  incoordination. 
If  we  can  get  a  person  to  write  only  with  the  parts 
necessary  and  not  with  all  the  other  muscles  in  the 
body,  we  have  sometimes  done  a  good  deal  to  check 
the  trouble. 

Occupational  neurosis,  then,  is  something  that  usu- 
ally happens  to  persons  predisposed  to  it  by  x  in  their 
constitution  and  not  to  any  one  who  happens  to  be 
exposed  to  a  great  strain  or  forced  to  do  a  given  process 
a  great  many  times.  If  we  could  find  out  which  people 
have  x  in  their  constitution  before  they  undertake  a 
trade,  we  could  prevent  a  great  deal  of  misery.  I  hope 
that  some  day  we  shall  be  able  to  do  this.  We  need 
some  test  to  show  that  a  person  is  more  sensitive  or 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

vulnerable  by  monotonous  repetition  of  movements 
than  other  people. 

There  remains  the  general  question  of  industrial 
overstrain  in  the  sense  of  overwork.  It  is  a  difficult  mat- 
ter to  estimate  for  the  reasons  already  given.  I  have 
almost  never  known  any  one  overworked  who  did  n't 
worry.  All  "overwork"  in  the  higher-paid  jobs  is 
really  worry;  but  I  haven't  had  enough  familiarity 
with  the  lower- paid  grades  of  work  to  say  anything 
about  overwork  there.  I  have  an  idea  that  there  is 
such  a  thing  as  overwork  among  the  lower-paid  occu- 
pations. Seven  days  a  week  and  twelve  hours  a  day 
certainly  seems  overwork.  But  it  is  very  hard  to  make 
any  definite  statements:  it  depends  so  much  more  on 
the  physical  and  psychical  conditions  under  which  the 
work  is  done,  on  the  general  nutrition  and  habits  of 
the  individual,  than  it  does  on  the  hours  of  work  or  the 
job.  At  one  time  we  got  to  the  point  where  we  thought 
we  could  put  some  salt  on  the  tail  of  this  particular 
phenomenon  and  catch  it.  We  were  told  that  there 
was  a  "  toxin  of  fatigue."  But  that  has  already  begun 
to  vanish  into  the  limbo  of  medical  fads  and  fancies. 
If  a  person  is  tired  he  is  tired,  and  that  is  all  there  is  to 
it.  We  don't  know  what  fatigue  is  any  better  than  we 
did. 

All  this  is  very  vague  and  most  unsatisfactory,  but 
that  is  the  present  state  of  our  knowledge,  in  my 
opinion. 

The  diseases  in  which  we  can  find  a  lesion  in  the 

446 


DISEASES  OF  THE  SKIN 

system  —  caisson  disease,  for  instance,  in  which  we 
can  prove  that  air  pressure  did  it,  or  lead-poisoning 
or  benzol-poisoning,  in  which  we  can  get  a  character- 
istic lesion  —  are  very,  very  few,  and  there  is  an 
immense  number  of  the  type  in  which  it  is  more  or 
less  guess-work  how  much  the  occupation  had  to  do 
with  it. 

Diseases  of  the  Skin 

^Pruritus  means  something  that  itches.  It  is  a  no 
more  definite  term  than  that.  It  is  not  a  disease,  but  a 
symptom.  A  person  who  has  an  itch,  without  anything 
more,  has  what  is  called  pruritus.  It  is  important  to 
distinguish  these  words,  which  are  merely  Latinized 
or  merely  Greek  equivalents  of  simple  English  symp- 
toms, from  words  which  really  name  a  disease,  —  that 
is,  a  group  of  symptoms  belonging  together. 

Erythema  means  redness.  When  one  is  burned  in  the 
sun,  one  has  an  erythema.  It  does  not  mean  anything 
more  than  that.  It  occurs  in  all  sorts  of  diseases  and  in 
health.  A  scarlet  fever  rash  is  erythema,  and  there  are 
many  more. 

Macule  means  a  red  or  brown  spot  on  the  skin. 

Papule  means  a  spot  that  is  raised. 

Pustule  is  a  spot  that  is  raised  and  has  pus  in  it. 

Vesicle  is  a  water  blister. 

Those  are  very  common  terms  which  are  worth 
knowing. 

Eczema  is  the  commonest  of  all  the  skin  diseases  that 

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come  to  a  physician.  It  is  brought  about  in  many 
cases  by  an  obvious  irritation.  A  chocolate-dipper, 
dipping  her  hands  into  the  sugar,  if  she  is  peculiarly 
sensitive  to  it,  will  get  "chocolate-dipper's  eczema"; 
twenty  other  girls  in  the  same  occupation  will  not.  If 
we  could  test  that  girl's  skin  before  she  went  into  the 
trade  and  discover  at  the  start  that  she  has  a  particular 
sensitiveness  in  relation  to  sugar,  it  would  be  good  for 
the  girl.  We  could  warn  her  against  chocolate-dipping. 

Parasites,  such  as  head  lice,  are  a  very  common 
cause  of  eczema  about  the  scalp  and  eyes.  When  a 
doctor  finds  eczema  he  at  once  looks  for  its  cause. 
Sugar  in  the  urine  brings  about  eczema  of  the  genitals. 
Friction  of  one  part  of  the  skin  over  another,  as  about 
the  breasts  in  women,  will  bring  about  eczema  in  the 
same  way,  especially  in  hot  weather.  Those  are  famil- 
iar examples  of  eczema  from  irritation. 

There  are  a  great  many  cases  of  eczema  not  yet  ex- 
plained at  all.  The  tendency  nowadays  is  to  explain 
them  as  something  wrong  with  the  food.  Dr.  C.  J. 
White,  of  the  Massachusetts  General  Hospital,  has 
been  experimenting  to  see  if  he  can  connect  the  food 
with  the  eczema  in  children  and  adults.  His  work  is 
not  yet  completed,  but  it  seems  possible  that  people 
who  are  subject  to  eczema  can  be  shown  to  be  abnor- 
mally sensitive  to  one  or  another  food.  We  now  test 
foodstuffs  by  putting  a  little  egg  or  meat  under  a  per- 
son's  skin  and  noticing  whether  the  skin  is  irritated  by 
it  more  than  the  average.  If  so,  then  the  same  food 

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DISEASES  OF  THE  SKIN 

substance  carried  into  the  body  by  mouth  is  possibly 
the  cause  of  the  eczema. 

The  extremes  of  life,  babies  and  old  people,  are  es- 
pecially subject  to  eczema.  With  babies  it  sometimes 
seems  as  if  the  eczema  lasts  until  they  grow  out  of  it  or 
grow  immune  to  it,  but  I  dare  say  that  is  an  unfair 
account  of  it.  Occasionally  we  can  relate  the  eczema 
very  definitely  with  something  wrong  in  the  baby's 
diet.  Social  workers  are  often  called  upon  to  help  out 
in  the  treatment  of  eczema  by  persuading  or  helping 
or  encouraging  the  individual  or  his  mother  to  keep  up 
the  treatment.  People  get  very  discouraged,  and  often 
take  just  enough  treatment  to  give  themselves  a  lot  of 
pain  without  persevering  long  enough  to  get  any  good 
from  it. 

Acne  is  the  familiar  "pimples"  which  people  are 
especially  subject  to  about  the  time  of  adolescence, 
probably  because  it  is  in  some  way  connected  with  the 
changes  in  the  skin  at  the  time  of  adolescence.  Acne 
is  due  to  bacteria  in  the  skin.  We  have  bacteria  in  our 
skin  deep  beneath  the  surface,  and  when  our  powers  of 
resistance  are  lowered  in  any  way,  they  multiply  and 
produce  an  acne  lesion.  A  precisely  similar  lesion  is 
sometimes  produced  by  drugs.  Two  very  familiar 
drugs,  the  iodide  and  bromide  of  potash,  will  produce 
an  acne  eruption  discouraging  the  skin  so  that  the  ordi- 
nary bacteria  flourish  there. 

There  are  two  things  that  can  be  done  for  acne.  One 

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is  cleanliness.  It  has  long  been  noticed  that  pimples 
are  very  prone  to  come  across  the  upper  part  of  the 
back  and  shoulders,  which  is  a  portion  that  often  es- 
capes thorough  attention  in  the  process  of  the  morning 
bath,  does  not  get  thoroughly  scrubbed  or  thoroughly 
towelled.  Hence  more  attention  to  that  place  will 
often  stop  acne.  There  are  some  cases,  then,  where 
cleanliness  is  all  that  is  needed.  There  are  other  cases 
where  it  does  no  good. 

Obstinate  cases  have  been  helped  by  vaccines.  A  vac- 
cine made  from  the  bacillus  present  in  the  skin,  and 
then  injected,  sometimes  stops  the  acne  by  rousing  a 
person's  vital  powers. 

An  important  thing  to  know  about  acne  is  that  it 
often  occurs  in  adolescence  and  stops  when  a  person 
grows  a  little  older.  We  see  many  a  young  man  or 
woman  very  much  discouraged  about  it  and  wondering 
if  it  is  going  to  last  all  their  lives.  But  they  will  find 
that  as  they  grow  older  it  will  disappear. 

Boils.  When  an  acne  pimple  goes  deeper  (or  starts 
deeper)  than  usual,  we  have  a  "boil."  The  cause  is  the 
same  as  acne  in  some  cases.  In  others,  general  con- 
dition plays  a  very  large  part.  Overtrained  athletes, 
and  others  whose  power  of  resistance  is  below  par, 
are  smitten  with  boils,  sometimes  in  crops  and  over 
months  of  time. 

One  boil  may  infect  the  adjoining  skin  and  start 
another.  Hence  the  most  scrupulous  cleanliness  is 
essential.  Each  boil  should  be  kept  covered  (with  a 

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DISEASES  OF  THE  SKIN 

collodion  dressing  or  otherwise)  so  that  its  discharge 
can  by  no  possibility  get  on  the  clothing  or  spread  to 
the  skin  near  by.  Clothing  (e.g.,  sweaters  or  trunks) 
which  may  have  gotten  infected,  should  be  thoroughly 
boiled. 

Most  boils  heal  without  interference.  If  healing  is 
delayed,  or  if  the  pus  is  obviously  working  its  way 
"  underground "  for  want  of  outlet,  the  boil  should  be 
opened.  A  doctor  is  the  best  judge  in  most  cases  and 
in  all  doubtful  cases  as  to  whether  an  opening  is 
needed  or  not. 

If  boils  recur  frequently  or  are  unusually  slow  in 
healing,  a  vaccine  made  from  the  germs  in  the  pus  is 
sometimes  useful  in  hurrying  things  up. 

Carbuncles.  When  pus  works  its  way  very  deeply 
among  the  fat  cells  on  the  back  of  the  neck  (occasion- 
ally elsewhere),  it  may  burrow  in  various  "shafts'* 
like  a  mine.  Serious  blood  poisoning  rarely  occurs,  but 
can  be  prevented  by  proper  surgical  treatment  and 
vaccines.  The  cause  usually  assigned  is  a  lowering  of 
the  patient's  vital  resistance  plus  a  working-in  of 
germs,  assisted  by  irritation  and  pressure  of  clothing 
on  the  back  of  the  neck. 

Impetigo  is  seen  especially  among  young  children, 
particularly  on  the  face.  It  is  contagious  from  part  to 
part  of  the  body  by  touch.  Little  vesicles  and  pustules 
form  and  dry  up  in  a  few  days,  but  the  patients  reinfect 
themselves  from  part  to  part.  We  don't  often  see  it 
except  in  children  and  usually  in  very  young  children. 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

It  is  a  school-children's  disease  and  has  no  serious  ef- 
fects ;  it  is  merely  a  bother,  but  it  is  common. 

Pediculosis  is  a  disease  which  every  social  worker 
and  teacher  should  be  able  to  recognize  and  to  make  a 
diagnosis  of.  The  diagnosis  is  not  difficult,  but  it  may 
be  a  matter  of  great  importance  to  us,  whether  we  our- 
selves contract  it  from  those  with  whom  we  deal  or 
whether  we  labor  to  prevent  its  spread.  The  charac- 
teristic thing  is  the  way  the  little  egg  sticks  to  the  hair. 
And  it  sticks.  The  little  white  particles  of  dandruff 
blow  off.  We  can't  blow  this  off.  Another  point  is  that 
it  is  always  fastened  on  parallel  with  the  hair,  never 
across  it.  There  is  nothing  else  of  this  size  and  look 
that  grows  parallel  with  the  hair.  Those  two  points 
enable  us  to  make  an  infallible  diagnosis.  A  great 
many  physicians  who  don't  happen  to  have  this  kind 
of  practice  don't  know  about  this  disease.  But  I  think 
every  social  worker  should  be  an  expert  in  its  diag- 
nosis. 

The  commonest  treatments  are  larkspur  and  kero- 
sene. Either  of  them  will  do  the  job. 

Until  recently  there  was  no  public  conscience  on  this 
subject.  It  was  so  common  that  nobody  paid  any 
especial  attention  to  it  in  the  public  schools.  Now 
there  is  getting  to  be  a  pretty  strong  public  opinion  on 
the  subject,  and  I  think  it  will  soon  disappear.  It  does 
no  harm,  of  course,  except  that  it  produces  attacks  of 
eczema  at  the  roots  of  the  hair  with  itching ;  to  these  I 
have  already  referred. 

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DISEASES  OF  THE  SKIN 

Scabies  (or  "the  itch")  is  a  much  less  common  dis- 
ease. There  is  a  good  deal  more  scabies  in  Boston  than 
in  most  parts  of  the  country,  because  of  our  large  im- 
migrant population.  Scabies  is  due  to  a  little  beetle 
which  burrows  its  way  into  the  skin ;  the  characteristic 
lesion  is  a  hole  such  as  any  one  would  make  if  trying  to 
burrow  into  the  ground.  It  is  popularly  called  "itch," 
which  describes  its  symptoms.  It  comes  most  where 
the  skin  is  thinnest;  that  is,  between  the  fingers.  It 
spreads  from  there  to  other  parts  of  the  hands  and 
body. 

We  can't  treat  an  individual  as  an  isolated  unit,  but 
have  to  treat  the  whole  family  as  a  unit.  It  is  very 
easy  to  cure,  provided  you  treat  all  members  of  the 
family  at  once. 

Dermatitis  venenata  is  the  general  name  for  inflam- 
mations of  the  skin  which  come  from  poisons  outside 
the  body.  Ivy,  sugar,  as  well  as  many  other  substances, 
may  cause  this.  Ivy  poison  is  the  commonest  type.  Of 
course  there  are  other  plants  beside  poison  ivy  that 
would  do  it.  Most  of  us  have  seen  or  experienced  poi- 
son ivy,  and  do  not  need  to  be  told  of  this  long  Latin 
name  which  is  attached  to  it.  Scrubbing  with  soap  and 
water  when  we  are  first  poisoned,  and  then  again  and 
again  later,  is  the  best  treatment. 

Psoriasis  is  always  getting  mixed  up  with  cirrhosis 
of  the  liver  because  the  spoken  names  sound  a  good 
deal  alike.  It  is  a  disease  which  practically  has  no 
symptoms  at  all  and  is  never  noticed  by  patients  unless 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

it  shows  on  the  face  or  hands;  but  we  don't  like  the 
looks  of  it.  It  is  a  chronic  red  scaling  rash  without  any 
itching  or  other  disturbance,  which  occurs  most  on  the 
front  of  the  knee,  the  tip  of  the  elbow  and  the  scalp.  I 
often  see  it  in  the  course  of  a  physical  examination, 
but  say  nothing  about  it.  But  in  a  certain  small  per- 
centage of  cases  it  gets  on  the  face  or  spreads  over 
the  whole  body  and  then  gives  a  lot  of  trouble.  It  is 
a  very  hard  disease  to  treat.  There  are  very  few 
dermatologists  who  say  with  any  confidence  that  they 
can  cure  it.  It  comes  and  goes.  When  I  was  inves- 
tigating PangSuey,  the  Chinese  "herb  doctor,"  I  saw 
a  case  of  psoriasis  which  he  was  supposed  to  have 
cured.  I  did  n't  feel  it  necessary  to  tell  the  lady 
that  the  rash  would  probably  come  back  in  a  few 
months. 

Urticaria  is  our  old  friend  the  ' 'hives,"  which  most 
people  have  had  some  experience  with,  and  which  in  the 
last  year  or  two  has  become  a  subject  of  special  interest 
because  of  certain  fundamental  ideas  about  disease 
which  hives  serves  to  illustrate.  I  refer  to  anaphy- 
laxis,  a  subject  already  mentioned  in  connection  with 
asthma. 

>Anaphylaxis  is  a  special  sensitiveness  to  certain  pro- 
tein substances.  Asthma  is  one  instance  of  what  hap- 
pens to  us  because  of  our  sensitiveness  to  feather  pil- 
lows or  a  horse's  breath  or  to  pollen,  or  other  kinds  of 
substances.  It  is  an  individual  thing,  born  in  us,  — 
luckily  born  in  comparatively  few  folks,  and  is  always 

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DISEASES  OF  THE  SKIN 

connected  with  a  particular  substance.  Asthma  and 
hives  are  two  of  the  best-known  examples  of  anaphy- 
laxis.  We  have  all  known  persons  who  have  hives 
every  time  they  eat  lobster  and  certain  kinds  of  shell 
fish.  A  friend  of  mine  has  the  most  intense  form  of 
anaphylaxis  caused  by  eating  egg  albumen.  If  she 
takes  egg  in  any  food,  although  she  does  not  know  it, 
she  will  break  out  with  an  attack  of  hives  very  soon 
after  she  has  taken  it.  This  particular  form  of  sensi- 
tiveness is  rare.  Some  people  break  out  with  hives 
after  eating  rye  or  oatmeal  on  account  of  sensitiveness 
to  these  particular  carbohydrates. 

We  don't  know  what  the  process  is  that  we  call 
"hives."  Some  people  have  it,  as  I  have  said,  from 
certain  foods.  They  take  a  laxative  and  get  better. 
There  are  people  who  always  get  it  under  certain  emo- 
tional conditions.  Presumably  faulty  chemistry  is 
brought  out  by  these  emotions.  Some  people  get  it 
when  they  exert  themselves  too  much  in  hot  weather. 
It  is  a  very  tantalizing  thing,  and  I  think  it  is  safe  to 
say  we  can  never  cure  it  unless  we  find  the  cause  and 
remove  it.  Nothing  that  we  can  do  on  the  outside 
makes  any  difference,  because  it  is  not  a  disease  of  the 
skin  any  more  than  scarlet  fever.  It  merely  happens  to 
show  itself  on  the  skin. 

Some  people  who  have  these  red,  angry,  itching  lumps 
on  their  skin  have  the  same  thing  in  their  throats 
and  clear  down  into  the  lungs.  There  may  be  pretty 
sharp  paroxysms  of  bronchitis  caused  in  this  way. 

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Hives  may  also  occur  in  the  intestines  and  cause  severe 
pain  sometimes  mistaken  for  appendicitis. 

A  person  who  has  been  subject  to  such  attacks  and 
gets  a  sudden  inexplicable  pain  may  be  suspected  of 
having  an  attack  of  internal  hives. 


CHAPTER  XVIII 

DISEASES   OF  THE  EYE  AND  EAR 

The  Eye 


I 


THERE  are  certain  parts  of  the  anatomy  that  I  have 
to  go  over  for  the  sake  of  the  names :  first,  the  cornea, 
the  front  window  of  the  eye ;  behind  that  a  space  filled 
with  watery  substance,  the  "aqueous  humor";  then 
the  iris,  the  colored  part  of  the  eye,  blue,  or  brown,  or 

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whatever  color  our  eyes  are;  behind  that  the  lens, 
which  is  a  transparent,  glassy-looking,  solid  thing, 
hitched  at  each  end  into  a  muscle  which  has  the  power 
of  pulling  tight  from  both  ends,  so  as  to  make  the  lens 
flatter,  or  letting  up  so  as  to  make  the  lens  more  con- 
vex. Of  course,  the  lens  does  different  things  to  the 
light  that  comes  through  it,  according  to  whether  it  is 
very  flat  or  very  convex,  and  the  lens  in  the  human  eye 
is  vastly  more  useful  than  it  could  otherwise  be  because 
it  has  this  property,  through  its  muscle,  of  flattening 
itself  or  thickening  itself.  Behind  that  is  the  main 
cavity  of  the  inside  of  the  eye,  filled  with  a  jelly-like 
substance  called  the  vitreous  humor.  Everything  be- 
hind the  lens  is  vitreous;  everything  in  front  aque- 
ous. The  back  of  the  eye  itself,  the  retina,  the  sensi- 
tive, seeing  part  of  the  eye,  is  simply  the  inside  back 
wall  of  the  eye. 

As  seen  in  cross-section  through  the  lids  the  con- 
junctival  sac  is  like  a  bag  whose  mouth  has  been  sewn 
up,  so  that  it  is  a  perfect  closed  sac.  It  dips  down  be- 
hind the  upper  lid  of  the  eye,  stretches  across  the  front 
of  the  eye,  and  dips  down  behind  the  lower  lid.  I  have 
not  tried  to  put  in  the  tear  duct,  because  it  has  not 
any  very  important  relation  to  the  diseases  that  we  are 
going  to  study.  The  white  part  of  the  eye  is  called  the 
"sclera,"  and  has  very  little  importance  except  that 
when  a  person  gets  jaundice  it  is  stained  yellow.  Tak- 
ing each  of  the  parts  named,  we  have  eye  troubles 
corresponding:  conjunctivitis,  keratitis  (in  the  cornea), 

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DISEASES  OF  THE  EYE  AND  EAR 

iritis,  cataract  (in  the  lens),  rare  and  unimportant 
troubles  in  the  vitreous  humor,  and  finally,  retonitis. 

Conjunctivitis,  inflammation  of  the  conjunctival  sac, 
is  most  familiar  in  "  pink-eye,"  which  is  a  contagious 
conjunctivitis  due  to  a  recognized  and  definite  micro- 
organism, running  a  self -limited  course  of  somewhere 
between  three  days  and  two  weeks,  and  getting  well  of 
itself.  We  do  not  know  anything  about  it  except  that 
it  is  contagious  and  that  it  is  mild. 

The  only  other  conjunctivitis,  and  that  is  of  very 
great  importance,  is  the  one  that  practically  all  social 
workers  are  familiar  with  as  gonorrheal  ophthalmia;  it 
starts  as  a  conjunctivitis  and  may  work  into  the  deeper 
parts  of  the  eye.  That  disease  has  been  already  re- 
ferred to  above,  so  that  no  further  description  is 
needed  here. 

The  most  serious  effect  of  the  inflammation  is  in  the 
cornea,  because  there  the  slightest  ulceration  may  re- 
sult in  a  scar,  and  a  scar,  if  it  is  in  the  middle  of  the 
eye  opposite  the  pupil,  means  blindness.  If  the  scar 
happens  to  be  on  the  lower  segment,  or  on  the  upper 
segment,  or  to  one  side,  it  will  be  unsightly,  but  have 
no  effect  on  vision.  But  if  it  happens  to  be  in  the  mid- 
dle, even  if  a  very  small  scar,  it  makes  a  very  serious 
impairment  of  vision.  In  all  asylums  and  schools  for 
the  blind  there  are  many  children  who  can  see  par- 
tially, including  many  whose  corneal  scars  are  such  as 
do  not  completely  shut  out  vision.  The  problem  of  the 
blind  includes  the  problem  of  the  partially  seeing. 

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When  we  get  smoke  or  cinders  or  any  foreign  body 
in  our  eyes  a  little  conjunctivitis  is  excited  —  the  red 
discoloration  that  we  are  familiar  with ;  it  has  no  special 
importance. 

The  cornea  being  such  a  delicate  membrane,  so 
easily  broken,  so  easily  wounded,  it  is  rather  extraor- 
dinary, it  seems  to  me,  that  so  many  of  us  get  through 
life  with  sound  eyes.  It  is  more  comprehensible  if  we 
notice  how  quickly  the  eye  defends  itself  by  the  quick 
winking  reflex.  The  winking  reflex  acts  far  more  quickly 
and  more  accurately  than  we  could  make  it  go  by  will. 
Moreover,  if  we  shut  the  eye  very  tight  and  frown  at 
the  same  time,  we  notice  that  there  is  a  big  cushion 
of  fat  over  the  eyeball  defending  the  eye  against  any 
blow  which  the  bones  of  the  orbit  do  not  care  for.  The 
eye  will  stand  a  good  deal  in  the  way  of  blows  because 
of  the  winking  reflex,  the  cushion  of  fat,  and  the  bones 
around  it. 

When  a  man  gets  a  black  eye,  he  has  usually  received 
a  blow  which  falls  chiefly  upon  the  bones,  but  some- 
what upon  the  eyelids.  If  just  a  drop  or  two  of  blood  is 
poured  out  there,  it  spreads  very  quickly  and  gives  the 
familiar  " black  and  blue"  appearance.  Another  result 
of  that  very  loose  structure  of  the  eyelids  is  that  any 
inflammation  of  the  skin,  such  as  ivy  poison  or  erysip- 
elas, if  it  happens  to  come  near  the  eye,  will  close  the 
eye  at  once  by  pufling  up  the  loose  tissues.  An  inflam- 
mation which  would  not  amount  to  anything  on  the 
finger,  if  it  happens  to  be  near  the  eye,  will  make  a 

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DISEASES  OF  THE  EYE  AND  EAR 

most  alarming  though  harmless  swelling.  I  was  called 
the  other  day  to  see  a  lady  who  thought  she  was  going 
to  die  because  a  hair  wash  she  had  put  on  the  night 
before  had  irritated  the  scalp  and  the  irritation  spread- 
ing to  the  skin  about  the  eyes  had  closed  them  tight. 
It  takes  a  very  slight  inflammation  to  do  that. 

In  spite  of  the  protection  that  I  have  spoken  of,  the 
cornea  gets  broken  by  flying  splinters  It  heals  very 
quickly,  but  it  heals  with  a  scar.  Bits  of  steel  flying  off 
from  a  machine  or  from  the  rail  of  the  elevated  cars  will 
stick  in  the  cornea  and  often  cause  a  scar.  If  the  frag- 
ment is  dirty  a  serious  sepsis  may  be  set  a-going. 

Interstitial  keratitis  is  becoming  a  problem  for  social 
workers  of  late  years,  largely  through  the  interest  of 
Dr.  Abner  Post  in  congenital  syphilis.  Interstitial  ker- 
atitis produces  the  dull,  steamy,  opaque  front  to  the 
eye  which  we  see  in  congenital  syphilitic  children. 
Much  is  accomplished  for  vision  in  favorable  cases 
by  anti-syphilitic  treatment.  As  a  rule  this  disease 
does  not  destroy  vision;  it  merely  makes  it  hazy. 

Phlyctenular  conjunctivitis  and  keratitis,  starting  in 
the  conjunctiva  and  getting  into  the  cornea,  is  a  dis- 
ease that  is  becoming  very  much  more  definitely  placed 
as  a  result  of  tuberculosis  in  the  last  three  or  four 
years.  It  used  to  be  said  that  it  came  in  "  scrofulous  " 
children  or  people  living  under  bad  conditions,  but  I 
think  that  those  who  study  it  most  now  say  that  it  is 
a  result  of  tuberculosis  —  probably  not  a  form  of  tuber- 
culosis itself,  but  bound  up  with  it,  an  offshoot  or  by- 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

product  of  it.  The  disease  starts  in  the  conjunctiva, 
beside  the  iris,  as  a  little  red  or  yellowish  patch,  and 
then  works  inward  toward  the  centre,  finally  on  to  the 
cornea,  where  it  makes  a  little  gray  point  about  as  big 
as  a  pin-head,  the  phlyctenule,  which  gives  the  trouble 
its  name.  From  the  social  point  of  view,  the  important 
thing  is  that  these  children  should  be  treated  as  if  we 
knew  they  had  tuberculosis  elsewhere,  which  in  all 
probability  they  have,  in  their  bronchial  lymphatic 
glands  or  some  other  inaccessible  place.  A  great  deal 
can  be  done  for  the  relief  of  these  children  by  fighting 
their  tuberculosis  through  the  methods  which  we  are 
all  now  familiar  with.  Local  treatment  is  not  as  a  rule 
much  emphasized  now.  Fresh  air  and  food  and  rest 
are  just  as  good  for  the  eye  as  they  are  for  the  lungs, 
and  may  help  to  ward  off  partial  blindness  —  the  effect 
of  corneal  ulceration  in  severe,  neglected  cases. 

The  iris  itself  has  its  inflammations  or  types  of  iritis, 
which  are  most  commonly  streptococcic,  what  we  used 
to  call  rheumatic  iritis.  Two  years  ago  we  had  a  big 
milk  epidemic  of  streptococcus  disease  starting  in 
Cambridge.  We  had  at  the  Massachusetts  General 
Hospital  a  great  many  cases  with  joint  and  heart 
trouble  and  iritis  —  all  three  starting  from  the  strep- 
tococcus, from  "rheumatism"  as  it  would  have  been 
called  formerly.  That  is  the  commonest,  the  mildest 
type  of  iritis.  It  gets  well  ordinarily  in  two  or  three 
weeks  and  is  not  followed  by  external  scars. 

Syphilis  is  the  commonest  cause  of  iritis.  It  has  much 

462 


DISEASES  OF  THE  EYE  AND  EAR 

more  serious  results  because  of  the  more  serious  char- 
acter of  the  infection ;  tuberculosis  much  more  rarely. 
"Rheumatism"  and  syphilis  produce  the  two  com- 
monest and  best  known  types  of  iritis.  One  of  the  di- 
agnostic points  is  that  the  red  which  we  see  in  any  of 
these  inflammations  of  the  iris  forms  a  ring  close 
around  the  iris  instead  of  being  spread  over  the  whole 
white  of  the  eye.  In  pink-eye,  a  conjunctivitis,  the 
whole  eye  is  pink. 

Iritis  is  a  thing  that  the  ophthalmologists  are  always 
much  interested  in,  because  there  is  something  that 
they  can  do  for  it.  The  iris  lies  very  close  to  the  lens. 
When  the  pupil  is  small  the  iris  touches  the  lens. 
Hence  inflammations  of  the  iris  are  very  apt  to  produce 
adhesions,  which  bind  the  pupil  to  the  lens,  and  make 
it  impossible  for  the  pupil  to  enlarge.  We  all  know  how 
the  pupil  shuts  down  when  we  face  a  strong  light,  and 
opens  up  when  we  are  in  the  dark.  That  movement  is 
abolished  when  an  iritis  has  not  been  treated  and  when 
adhesions  have  occurred,  binding  it  to  the  lens.  These 
adhesions  can  be  prevented  by  giving  atropin,  which 
keeps  the  pupil  big,  paralyzes  the  ciliary  muscle,  so  that 
the  iris  is  kept  away  from  the  lens  and  does  not  stick 
to  it.  This  atropin  paralysis  of  the  iris  is  kept  up  until 
the  attack  of  iritis  has  passed  by.  Besides  this,  general 
constitutional  or  hygienic  treatment  is  all  that  is  to 
be  done  in  the  rheumatic  form.  In  the  syphilitic,  of 
course,  anti-syphilitic  medicines  are  used. 

The  lens  itself  is  subject  to  practically  only  one  set  of 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

diseases,  which  go  by  the  name  of  cataract.  The  one 
disaster  that  happens  to  the  lens  is  that  it  gets  opaque. 
What  is  called  " senile  cataract, "  or  "hard  cataract," 
is  the  commonest  type.  There  is  also  the  soft  cataract 
such  as  diabetics  get  (the  so-called  "  diabetic  cata- 
ract"), and  finally,  the  congenital  cataract  of  young 
children  —  three  types. 

Senile  cataract  is  the  one  in  which,  on  the  whole,  the 
most  brilliant  results  that  I  have  seen  have  been  se- 
cured. With  a  very  thin  knife  the  surgeon  cuts  through 
the  edge  of  the  cornea  at  the  point  where  there  is  no 
harm  in  making  a  scar,  cuts  out  a  bit  of  the  iris,  cuts  the 
muscles  holding  the  lens,  and  takes  it  out.  That  seems 
radical,  but  by  putting  a  glass  lens  in  a  pair  of  glasses 
in  front  of  the  eye,  a  person  who  has  been  practically 
blind  before  is  sometimes  able  to  see  even  fine  print,  a 
perfectly  marvellous  transformation.  The  operation 
is  done  under  cocaine,  without  any  pain,  so  that  the 
patient  does  not  have  all  the  discomforts  of  a  general 
anaesthetic,  like  ether.  I 

The  soft  cataract,  the  diabetic,  is  not  so  easily  dealt 
with,  because  of  the  more  serious  nature  of  the  under- 
lying disease.  Diabetics  do  not  bear  surgery  of  any 
kind  very  well ;  it  is  hard  to  get  their  tissues  into  good 
condition. 

Of  the  causes  of  congenital  cataract  little  is  known. 
At  the  Massachusetts  Eye  and  Ear  Infirmary  they  are 
particularly  interested  from  the  social  point  of  view, 
because  these  children  can  be  helped  a  good  deal  if 

464 


DISEASES  OF  THE  EYE  AND  EAR 

they  will  come  in  every  two  or  three  months  for  the 
slight  operation  called  "needling."  They  are  very 
anxious  at  the  Eye  and  Ear  Infirmary  to  have  some- 
body devote  his  time  to  getting  these  children  in  as 
often  as  they  ought  to  come  for  this  purpose. 

Questions  and  Answers 

Q.  What  causes  cataract? 

A.  I  don't  think  any  one  knows.  We  know  that  the  tend- 
ency all  over  the  body  in  old  age  is  to  get  hard.  Our  carti- 
lages, our  joints,  our  kidneys,  our  hearts,  everything  stiffens 
up,  and  the  sort  of  tissue  that  cataract  forms  in  the  lens  is 
like  the  tissue  which  is  formed  everywhere  in  the  bodies  of 
elderly  people. 

Q.  If  a  person  has  cataract  in  one  eye,  is  he  bound  to  have 
it  in  the  other? 

A.  He  is  very  likely  to  have  it  in  both  eyes,  first  one  and 
then  the  other. 

Q.  What  is  the  cause  of  the  congenital  form? 

A.  I  do  not  know.  It  is  not  syphilitic  apparently.  I  do 
not  know  what  the  cause  is. 

We  have  been  going  backwards  —  conjunctiva,  cor- 
nea, iris,  lens.  We  have  come  now  to  the  vitreous 
humor,  in  which,  as  I  have  said,  there  are  no  important 
diseases;  next  comes  the  retina. 

The  retina  has  important  diseases,  especially  a  com- 
plication of  diseases  in  the  heart  and  kidney.  In  dis- 
eases of  the  heart  and  kidney  there  occur  changes  in 
the  retina,  which  may  hurt  vision  badly.  Quite  often  a 
patient  has  had  trouble  with  sight  and  is  referred  to  a 
hospital  for  treatment  of  the  heart  or  kidney,  a  trouble 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

which  has  first  been  found  by  looking  at  the  eye.  In 
looking  into  the  back  of  the  eye,  we  are  looking  into 
the  interior  of  the  body  in  quite  an  extraordinary  way. 
We  can  see  arteries  and  veins,  and  even  very  slight 
arteriosclerosis  can  be  detected  in  the  arteries  of  the 
eye  when  we  cannot  find  it  out  anywhere  else.  The 
other  day  in  a  series  of  examinations  of  supposedly 
healthy  people,  Dr.  George  Derby  came  across  a  per- 
son of  thirty-nine  in  whose  eyes  he  saw  arteriosclerosis. 
That  is  young  for  arteriosclerosis,  and  when  he  came 
to  question  this  patient  he  found  that  his  mother  had 
died  of  premature  arteriosclerosis  at  about  that  age,  so 
that  there  was  apparently  an  inherited  tendency  to 
arterial  disease.  In  Bright's  disease  the  retinal  changes 
are  mostly  hemorrhages  and  their  results ;  little  hemor- 
rhages at  the  back  of  the  eye  show  by  a  little  red  spot, 
and  then,  as  this  is  absorbed,  a  white  spot  against  a  red 
background.  Such  hemorrhages  hurt  vision  much  or 
little  according  to  their  size  and  position.  We  have  no 
treatment  for  them. 

The  two  eyeballs  are  like  apples  on  the  ends  of  two 
crossed  sticks.  The  two  sticks  are  the  optic  nerves. 
These  optic  nerves,  as  they  come  into  the  retina  at  the 
back  of  the  eye,  can  be  seen  with  the  ophthalmoscope. 
It  is  the  only  place  where  we  can  look  at  a  nerve  bare, 
uncovered  by  anything.  Very  early  disease  in  the  optic 
nerves,  neuritis,  can  be  seen  there  face  to  face,  as  it 
were. 

The  commonest  type  of  neuritis  accompanies  tumors 

466 


DISEASES  OF  THE   EYE  AND  EAR 

.of  the  brain.  In  people  suffering  from  very  severe 
headaches  sometimes  the  whole  question  of  diagnosis 
may  depend  on  what  the  ophthalmologist  sees  as  he 
looks  at  the  end  of  the  nerve. 

Optic  atrophy  is  a  very  familiar  result  in  tabes  dor- 
salis  (locomotor  ataxia).  Many  a  case  of  blindness 
which  turns  up  at  an  eye  and  ear  hospital  is  nothing 
but  tabes,  showing  itself  in  that  particular  nerve,  as 
well  as  in  its  ramifications  farther  back  toward  the 
spinal  cord.  We  have  already  said  that  these  nerves 
cross.  That  is  true  of  almost  all  the  nerves  in  the 
body.  The  right  side  of  the  brain  corresponds  to 
the  left  arm  and  leg.  If  a  person  has  a  paralysis  of  the 
right  arm  and  leg,  we  can  usually  be  sure  that  there  is 
trouble  on  the  left  side  of  the  brain. 

There  is  no  treatment  for  atrophy  of  the  optic  nerve. 
For  early  optic  neuritis  we  can  do  something  in  case 
the  cause  (tumor,  hemorrhage,  syphilis)  can  be  re- 
moved. 

I  have  said  nothing  yet  about  eye  muscles.  The  best 
way  to  think  of  the  muscles  of  the  eye  is  to  think  of  the 
way  a  horse's  head  is  harnessed.  We  have  a  rein  at 
each  side  that  will  pull  his  head  to  the  right  or  left,  a 
check-rein  over  the  top  to  pull  his  head  up,  and  a  mar- 
tingale to  pull  his  head  down.  If  we  think  of  ourselves 
as  behind  the  globe  of  the  eye,  driving,  we  have  these 
four  muscle-bands  by  pulling  on  which  we  could  turn 
the  eye  up  or  down  or  right  or  left.  That  is  where  we 
would  naturally  suppose  Nature  would  stop,  but  like 

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A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

everything  else  in  Nature  the  eye  does  not  fit  into  an 
orderly  plan.  There  are  two  extra  reins,  six  muscles 
hitched  to  the  eye,  instead  of  four.  The  four  would  do 
all  the  work.  What  we  have  six  for  I  have  not  the 
slightest  idea.  I  do  not  know  of  a  better  example  of 
the  fact  that  Nature  never  does  what  we  think  she  is 
going  to  do. 

The  importance  of  those  muscles  in  disease  is  that 
they  may  produce  squints  and  headaches.  When  one 
muscle  is  a  little  shorter  than  the  others  and  tends  to 
pull  the  eye  over,  we  have  one  type  of  eye-strain.  If  a 
muscle  is  very  much  too  short,  the  eye  squints.  The 
squints  are  inconvenient  and  disfiguring.  Probably 
we  have  all  seen  some  very  extraordinary  operations 
whereby  a  person  with  quite  crooked  eyes  has  had  his 
eyes  put  straight  by  cutting  the  eye  muscles. 

The  subject  of  troubles  in  muscular  balance,  when 
one  muscle  is  a  little  too  short,  but  not  enough  to  make 
a  squint,  brings  us  to  the  general  subject  of  eye-head- 
aches, of  which  pretty  much  everybody  has  some  ex- 
perience. Eye-strain  as  a  cause  of  eye-headaches  is  due 
partly  to  this  trouble  which  I  have  just  spoken  of,  but 
much  more  often  to  astigmatism.  Astigmatism  means 
that  in  the  front  of  the  eye,  the  cornea,  which  ought 
to  be  a  perfect  globe,  there  is  one  of  the  curves  across 
the  eye,  or  more  than  one,  which  is  not  a  perfect  seg- 
ment of  a  circle.  It  is  too  flat  or  not  flat  enough.  In  a 
perfect  eye  all  the  curves  are  alike,  but  in  most  peo- 
ple's eyes  they  are  not ;  in  some  one  direction  as  we  go 

468 


DISEASES  OF  THE  EYE  AND  EAR 

across,  either  up  or  down  or  transversely,  the  curve  is 
not  perfect.  I  suppose  that  this  is  the  commonest  of  all 
eye  troubles,  and  the  commonest  of  all  causes  of  ocular 
headaches.  I  believe  that  ocular  disease  as  a  cause  of 
headache  is  less  thought  of  than  it  was  ten  years  ago. 
In  Boston,  perhaps,  fewer  headaches  are  called  ocular 
headaches  than  in  some  other  cities.  Of  course  I  am 
referring  to  the  different  views  of  different  eye  special- 
ists. The  specialists  here,  I  think,  are  less  prone  to 
prescribe  glasses  than  those  in  other  cities. 

Near-sightedness  and  far-sightedness  are  due  to  de- 
fects in  the  shape  of  the  eye.  The  near-sighted  eye  is 
too  long  from  before  backwards ;  myopia  is  the  techni- 
cal term  for  that,  and  hypermetropia  the  term  for  far- 
sightedness, such  as  old  people  generally  have.  Those 
three  diseases  —  astigmatism,  myopia,  and  hyperme- 
tropia —  are  the  troubles  for  which  glasses  are  gen- 
erally fitted.  They  form  a  class  of  work  by  themselves 
and  are  called  errors  of  refraction.  In  hospitals  the 
man  who  works  to  correct  these  errors  often  does 
nothing  else,  and  in  many  hospitals  the  refractionist 
is  paid.  The  optometrist  is  the  gentleman  who  thinks 
he  can  learn  this  part  of  the  eye  without  learning  the 
rest.  Every  year  in  the  Massachusetts  Legislature 
there  has  been  a  contest  as  to  whether  the  optometrist 
ought  to  be  registered  and  licensed  to  practice.  The 
ophthalmologists  contend  that  we  cannot  safely  fit 
people  with  glasses  without  a  good  knowledge  of  the 
rest  of  the  eye  and  its  diseases. 

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A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

A  rather  mysterious  disease  of  the  eye,  glaucoma, 
means  that  the  fluids  inside  the  eye  are  pressing  too 
hard  to  get  out.  It  involves  an  increase  of  tension 
within  the  eye,  comparable  to  high  blood  pressure  in 
the  arteries,  although  it  has  no  connection  with  that. 
Glaucoma  may  produce  headaches  or  may  produce  no 
symptoms  whatever.  Sometimes  it  is  discovered  just 
as  part  of  a  routine  examination  by  eye  specialists.  It 
is  a  very  serious  disease,  for  it  often  leads  to  blindness, 
but  luckily  a  rare  one.  On  account  of  this  disease  es- 
pecially the  eye  specialists  are  coming  to  feel  that  the 
eye  should  be  examined,  as  a  matter  of  routine,  once  in 
so  often,  because  glaucoma  may  come  on  without  any 
symptoms  whatever. 

Last  year  a  group  of  physicians  examined,  as  a  mat- 
ter of  precaution,  one  hundred  supposedly  healthy 
members  of  the  Boston  Economic  Club,  among  them 
one  gentleman  with  perfectly  good  eyesight  and  no 
headaches ;  so  far  as  he  knew  he  was  perfectly  sound  in 
every  respect.  He  was  found  by  our  group-oculist  to 
have  glaucoma,  and  in  a  stage  in  which  operation  could 
make  a  great  difference  in  saving  his  eyesight.  He  has 
had  the  operation  since.  This  case  made  a  great  im- 
pression on  all  of  us  who  examined  that  group  of  men  ; 
it  certainly  exemplified  the  value  of  routine  group-ex- 
aminations. 

Q.  What  about  the  acute  form  of  glaucoma? 
A.  That  is  more  likely  to  be  recognized.    It  causes  head- 
aches and  vomiting  and  halos  or  rainbows  about  any  bright 

470 


DISEASES  OF  THE   EYE  AND   EAR 

light.  It  is  more  difficult  to  stop,  as  I  understand  it,  than  the 
chronic  type,  but  less  likely  to  lead  to  the  tragedy  of  being 
overlooked  until  it  is  too  late.  Nobody  knows  the  cause  of 
glaucoma. 

Trachoma,  a  disease  that  twenty  years  ago  was  prac- 
tically unknown  here,  is  now  pretty  common  both  on 
the  eastern  coast  and  among  the  American  Indians,  in 
many  parts  of  the  Blue  Ridge  country  in  Kentucky 
and  Tennessee,  and  in  other  sections  of  country  cut 
off  from  the  world.  Trachoma  is  a  contagious  disease, 
although  we  do  not  know  the  germ.  It  is  contagious 
from  person  to  person  and  very  difficult  to  cure, 
though  not  impossible.  It  is  a  disease  that  we  don't 
often  see  in  the  streets  now,  because  so  many  people's 
attention  has  been  attracted  to  it  and  patients  are 
hustled  away  for  treatment.  The  appearance  that  we 
may  see  is  the  granulated  lids,  or  little  elevations,  red 
mounds  on  the  inner  surface  of  the  eyelids,  which 
make  them  look  very  red  and  turn  out,  and  give  the 
person  a  look  of  great  misery,  even  though  there  is  not 
much  suffering  to  the  disease.  It  does  not  generally 
cause  blindness,  but  in  old,  neglected  cases  it  may  do 
so.  Starting  in  the  lids  and  being  confined  to  them  for 
a  long  time,  if  it  is  not  treated  it  may  get  on  to  the  eye- 
ball itself  and  so  be  serious.  Direct  surgical  treatment 
of  the  eyelids  can  do  a  great  deal  to  check  or  to  allevi- 
ate it. 

Toxic  amblyopia   means  partial  or  total  blindness 
without  any  known  lesion  of  the  eye  to  explain  it. 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

Poisoning  of  the  tissues  is  the  cause.  The  poisons  of 
uremia,  diabetic  acidosis,  malaria,  also  tobacco,  al- 
cohol, and  lead,  besides  quinine,  arsenic,  and  methyl 
alcohol  are  responsible.  Most  cases  recover  when  the 
poison  is  out  of  the  system. 

Diseases  of  the  Ear 

I  have  been  very  much  impressed,  in  looking  up  the 
eye  and  ear  statistics  at  the  Massachusetts  Eye  and 
Ear  Infirmary,  to  find  that  diseases  of  the  ear  are  prac- 


E 

Fig.  31. —  Semidiagrammatic  section  through  the  right  ear  (Czermak): 
G,  External  auditory  meatus;  T,  membrana  tympani;  P,  tympanic  cav- 
ity; o,  fenestra  ovalis;  r,  fenestra  rotunda;  B,  semicircular  canal;  S, 
cochlea;  Vt,  scala  vestibuli;  Pi,  scala  tympani;  E,  Eustachian  tube. 


tically  all  one  disease  —  otitis  media.  That,  with  its 
various  complications,  is  the  ordinary  child's  ear  dis- 
ease. Wax,  of  course,  comes  well  up  in  the  list,  but  it 

472 


DISEASES  OF  THE  EYE  AND  EAR 


is  hard  to  take  that  for  a  disease.  The  following  are  the 
statistics  of  the  diseases  most  often  seen  both  in  the 
wards  ("  House")  and  in  the  Out- Patient  Department 
(O.  P.  D.)  of  this  hospital:  — 


House 

O.  P.  D. 

Total 

Otitis  media  

6lQ 

1640-]- 

22  en  4- 

Otosclerosis  

2 

2O 

22 

Labyrinthitis 

4" 

AC 

4.Q 

Wax. 

I56O 

1560 

Eczema     

IT.2 

1^2 

The  passage  that  leads  into  the  ear  from  the  outside 
comes  to  an  end  in  a  flat  membrane  which  we  call  the 
"drum."  It  is  in  this  passage  that  wax  accumulates. 
From  the  inner  side  of  the  drum  there  comes  a  tube 
(the  Eustachian  tube)  leading  directly  from  the  throat 
to  the  middle  ear.  This  cavity,  which  we  call  the 
"middle  ear,"  is  thus  entered  from  two  sides,  (a)  the 
outside  passage  normally  blocked  by  the  drum  mem- 
brane, and  (b)  the  passage  from  the  throat  through  the 
Eustachian  tube  which  is  open  and  has  no  membrane 
to  close  it.  Through  this,  the  middle  ear,  where  most 
ear  troubles  arise,  is  often  infected  from  the  throat. 
The  ear  (i.e.,  the  tube)  gets  "stopped  up."  " Catarrhal 
deafness"  is  the  term  used  for  disease  of  the  ear  which 
results  from  a  cold  or  catarrhal  inflammation  travelling 
up  the  Eustachian  tube.  In  that  cavity  of  the  middle 
ear  there  are  a  great  number  of  mysterious  things 
which  after  hundreds  of  years  of  study  are  still  mys- 

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terious.  There  are  three  sets  of  objects:  (i)  A  set  of 
bones  smaller  than  the  little  finger  nail  (one  like  a 
horse's  stirrup  and  called  the  "stirrup  bone,"  another 
shaped  like  a  mallet).  These  minute  bones  hitch  on  to 
the  drum  on  its  inner  side  and  communicate  its  vibra- 
tions to  the  auditory  canal,  and  to  the  nerve  leading  to 
the  brain.  We  hear  with  our  brains,  as  we  see  with  our 
brains,  through  a  nerve.  (2)  The  organ  of  balance  (or 
the  semicircular  canals)  which  for  some  reason  or  other 
is  put  in  here.  It  has  nothing  to  do  with  hearing.  Then 
(3)  there  is  the  hearing  apparatus  itself,  which  seems 
to  be  a  thing  more  or  less  like  a  grand  piano  with 
strings  of  different  lengths,  corresponding  to  the  dif- 
ferent tones  which  we  hear. 

Practically  the  only  aural  disease  that  laymen  have 
to  know  about  is  otitis  media,  or  disease  of  the  middle 
ear,  which  gets  in  from  the  throat  and  breaks  through 
the  drum,  either  spontaneously  or  with  the  aid  of  the 
surgeon's  knife.  The  most  important  help  we  can  give 
is  to  puncture  the  drum.  This  is  a  delicate  operation, 
—  the  ordinary  physician  is  not  able  to  do  it  well,  — 
delicate  because  the  drum  is  hard  to  see,  because  it  is 
hard  to  manipulate  the  knife  correctly,  and  because  the 
operation  is  very  painful.  It  is  all  over  in  a  second  and 
people  are  apt  not  to  etherize  a  child,  but  this  is  a  mis- 
take. It  is  the  sort  of  job  which  a  child  never  forgets, 
and  it  makes  him  hostile  to  all  the  world  which  circles 
around  a  doctor's  office. 

Otitis  media  is  a  suppuration  or  inflammation,  mild 

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DISEASES  OF  THE  EYE  AND   EAR 

or  severe,  acute  or  chronic,  which  is  spread  to  the  ear, 
as  I  have  said,  chiefly  from  the  throat.  It  may  also  be 
the  result  of  tuberculosis  or  of  other  germs.  The  bacil- 
lus of  influenza,  or  of  typhoid,  can  get  up  the  Eusta- 
chian  tube  and  produce  otitis  media.  We  have  stopped 
this  for  the  most  part  in  typhoid  by  cleaning  the  pa- 
tient's mouth  every  three  hours;  that  is  one  of  the 
chief  duties  of  nurses  in  typhoid. 

Besides  its  great  frequency  in  children,  and  besides 
the  fact  that  the  most  important  thing  to  do  is  to  punc- 
ture the  drum,  the  other  fact  which  laymen  should 
know  is  that  this  inflammation  can  very  easily  perfo- 
rate through  the  wall  on  the  inside  of  the  ear  and  get 
into  the  mastoid  bone,  which  is  of  itself  of  importance 
because  it  is  so  near  the  brain.  Cases  of  otitis  media 
may  not  only  spread  into  the  mastoid,  which  cannot 
be  prevented,  but  may  reach  the  brain  and  cause  seri- 
ous, often  fatal,  meningitis.  By  opening  into  the  mas- 
toid bone  we  can  make  the  pus  drain  out  instead  of 
going  into  the  brain.  Thus  we  may  prevent  meningitis. 
It  is  a  delicate  operation. 

There  are  three  common  procedures  done  by  the  ear 
specialist:  he  punctures  the  drum,  he  chisels  open  the 
mastoid  bone,  and  he  inflates  the  middle  ear.  This  last 
is  a  procedure  for  opening  the  Eustachian  tube.  The 
patient  is  given  a  glass  of  water  to  drink.  Just  as  he 
swallows  the  doctor  blows  air  forcibly  up  the  nostril. 
The  air  goes  in  through  the  Eustachian  tube  and  opens 
it  up,  relieves  that  wooden,  stopped-up  feeling  that 

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we  often  have  from  a  cold,  and  lets  air  (which  is  very 
necessary)  into  the  middle  ear  back  of  the  drum. 

Q.  Can  the  drum  be  shattered  by  a  loud  noise? 

A.  I  do  not  see  why  not.  I  have  heard  of  it.  In  dealing 
with  caisson  disease  I  mentioned  the  group  of  cases  which 
we  have  seen  at  the  Massachusetts  General  Hospital  this 
year,  broken  ear  drum  from  air  pressure.  I  do  not  see  why 
it  should  not  happen  from  tremendous  sound.  The  drum 
usually  mends  itself  with  extraordinarily  little  damage  to 
hearing.  Of  course  the  drum  is  not  the  organ  of  hearing.  Its 
use  is  mostly  to  keep  the  outside  world  out.  Scars  of  healed 
wounds  in  the  drum  ordinarily  do  not  interfere  with  hearing. 

The  causes  of  deafness  are  in  two  main  groups:  (i) 
Trouble  in  the  sound-conducting  apparatus  (wax,  and 
otitis  media,  blocked  Eustachian  tube).  (2)  Trouble 
in  the  labyrinth  or  in  the  nerve  leading  to  the  brain. 
In  the  labyrinth  syphilis  is  the  commonest  cause 
of  deafness  in  young  people  and  hemorrhage  in  old 
people  as  part  of  arteriosclerosis. 

There  is  another  form  of  ear  trouble  which  is  con- 
genital, very  apt  to  be  inherited  from  one  generation 
to  another,  especially  if  two  deaf  people  of  this  particu- 
lar type  marry  each  other.  Ordinary  deafness  acquired 
from  causes  such  as  I  have  mentioned  is  not  inherited, 
but  people  who  are  congenitally  deaf,  the  congenital 
deaf  mutes,  if  they  marry  are  very  apt  to  have  deaf 
children.  Some  part  of  the  machinery  of  hearing  is 
absent,  blocked  or  malformed.  In  some  States  there  is 
a  law  against  the  marriage  of  such  persons. 


CHAPTER  XIX 

EMERGENCIES  —  HOME   MEDICINE  —  PERSONAL 
HYGIENE 

Emergencies,  and  the  Methods  of  Dealing  with  them 

CHOKING  is  perhaps  one  of  the  commonest  emergen- 
cies encountered,  especially  with  children.  Most  of  us 
have  seen  more  or  less  mild  cases  of  it,  but  it  may  be  a 
very  serious  matter.  Children  have  died  from  getting 
an  unchewed  mass  of  meat  into  the  windpipe,  and  at 
any  moment  what  seems  like  a  laughable  matter  may 
become  crucial.  The  familiar  remedy  —  slapping  on 
the  back  —  really  does  good,  because  it  stimulates 
coughing,  and  if  the  child  can  cough  he  is  more  likely 
to  expel  whatever  has  got  stuck.  If  that  does  not  do  it, 
and  the  child  goes  on  to  get  black  in  the  face,  there  is 
every  reason  to  hurry  and  do  the  only  thing  we  can 
do,  which  is  to  put  the  finger  down  the  throat  and  get 
the  thing  out.  We  must  take  time  enough,  however, 
and  be  careful  not  to  push  the  mass  farther  down. 
Of  course,  if  we  had  a  pair  of  pincers  or  forceps,  that 
would  be  the  best  thing ;  but  if  the  child  is  fairly  small 
and  our  fingers  are  fairly  long,  we  can  generally  get 
around  whatever  there  is  and  hook  it  out.  The  child 
will  die  within  a  minute  or  two  if  there  is  complete 
obstruction.  Generally  the  child  does  not  undertake 

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to  swallow  anything  as  big  as  this,  and  so  can  cough  a 
few  times  and  get  it  out.  Holding  him  upside  down  is  a 
method  intermediate  in  value  between  slapping  on  the 
back  and  trying  to  hook  the  matter  out. 

Q.  If  it  happens  to  be  in  the  pharynx  instead  of  the  wind- 
pipe, can't  you  push  it  down? 

A.  Yes ;  but  it  is  hard  to  be  sure  that  you  are  not  poking 
it  into  the  windpipe. 

In  putting  the  hand  into  anybody's  mouth,  it  is 
well  to  know  how  to  prevent  one's  self  from  being  bit- 
ten. There  is  one  traditional  and  perfectly  sure  way 
to  prevent  it  —  to  put  the  finger  on  the  outside  of  the 
cheek  and  press  the  soft  part  of  the  cheek  in  between 
the  person's  jaws.  Then,  when  he  bites  he  bites  his 
cheek  and  so  stops.  That  is  constantly  done  in  dealing 
with  struggling  or  unconscious  patients. 

Control  of  bleeding.  I  advise  against  trying  to  put  on 
a  tourniquet;  that  is,  putting  .a  bandage  above  the 
bleeding  point  on  the  leg  or  arm  and  twisting  until  we 
make  it  tight  enough  to  close  the  arteries  and  so  to  stop 
bleeding.  The  ordinary  statement  is  that  bleeding  is 
either  from  a  vein  or  an  artery,  and  that  if  it  is  from  a 
vein  you  do  not  need  to  put  on  a  tourniquet,  but  if 
from  an  artery  you  do.  That  is  a  mistake.  In  my  opin- 
ion it  is  not  a  good  thing  to  try  to  put  on  a  tourniquet, 
We  can  either  stop  the  bleeding  in  other  ways  or  if  we 
can't  we  are  likely  to  do  as  much  harm  as  good  in  our 
attempts.  The  best  way  to  stop  bleeding  is  by  the 
application  of  gauze  and  pressure.  The  mesh  of  the 

478 


EMERGENCIES 

gauze  is  what  we  need,  and  any  mesh  will  do.  Mos- 
quito netting  will  do.  The  old-fashioned  habit  of  using 
cobwebs  was  dirty  but  effective.  Stuffing  gauze  right 
into  the  wound  and  pressing  hard  will  stop  practically 
any  hemorrhage  that  one  can  stop  at  all.  Following 
this  rule  avoids  the  chances  of  doing  more  harm  than 
the  hemorrhage  itself  will  do.  Anybody  who  has  seen 
many  operations  knows  that  very  serious  hemorrhages 
happen  and  are  controlled  by  gauze  and  pressure 
without  any  attempt  to  do  anything  else.  What  the 
doctor  calls  "  gauze  "  is  ordinary  cheese  cloth  sterilized 
by  baking. 

The  one  thing  most  important  to  have  as  a  household 
remedy  is  sterilized  gauze,  gauze  that  we  do  not  have  to 
stop  and  question  the  cleanliness  of. 

We  should  not  try  to  make  the  distinction  between 
arterial  and  venous  hemorrhages.  Arterial  blood  comes 
in  jets  instead  of  flowing  steadily,  as  venous  or  capil- 
lary blood  does ;  but  as  both  are  to  be  treated  alike  so 
far  as  the  layman  is  concerned,  their  difference  is  not 
important. 

The  pressure  is  just  as  important  as  the  gauze.  I 
once  was  up  in  the  woods  with  another  man  and  an  axe 
quite  far  off  from  any  help.  The  other  man  cut  his  foot 
badly  with  the  axe.  There  was  no  gauze  and  no  possi- 
bility of  any  help.  I  took  hold  of  the  sides  of  the  cut 
and  pressed  them  together  as  hard  as  I  could.  Bleeding 
stopped  at  once.  I  still  held  it,  and  within  an  hour 
it  no  longer  needed  to  be  held.  It  would  have  stopped 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

quicker  if  we  had  had  gauze,  but  the  pressure  was 
enough  to  do  it. 

When  the  hemorrhage  has  stopped,  what  shall  we  do 
with  the  gauze?  Better  leave  it  there  until  the  doctor 
comes.  It  won't  do  any  harm  to  leave  clean  gauze  in  a 
wound  for  even  twenty-four  hours.  This  applies  to 
every  sort  of  bleeding  —  to  very  severe  nose-bleeds,  to 
bleeding  after  a  tooth  is  extracted,  or  from  cuts  or 
wounds  of  any  kind.  The  whole  matter,  then,  is  very 
much  simplified  if  one  does  not  have  to  go  into  the 
technique  of  trying  to  stop  bleeding  by  pressing  on  the 
artery  above  the  point,  as  most  treatises  say. 

I  suppose  the  bleeding  we  see  most  often  is  a  nose- 
bleed, and  the  reason  it  makes  difficulty  is  that  we 
do  precisely  the  wrong  thing  —  bend  forward  over  a 
basin.  That  position  compresses  the  veins  at  the  base 
of  your  neck,  and  keeps  more  blood  in  the  head,  so  that 
bleeding  is  kept  up.  The  person  should  lie  down  on  his 
back.  A  certain  amount  of  blood  will  go  down  into  the 
stomach,  but  that  does  no  harm.  In  the  majority  of 
cases  the  bleeding  will  stop  by  lying  down  and  keeping 
quiet.  Otherwise  it  has  to  be  stopped  in  the  way  I 
have  said,  by  pressure  and  gauze  —  stuffing  gauze  up 
the  nostril,  putting  it  into  place  with  a  pencil.  We 
make  a  long  strip  like  a  tape,  put  one  end  in  and  keep 
packing  more  and  more  up  until  we  have  filled  the 
nostril  tight.  In  the  vast  majority  of  cases  that  will 
stop  it. 

We  have,  I  suppose,  seen  people  drink  salt  and  water 

480 


EMERGENCIES 

or  put  cold  doorkeys  on  the  back  of  the  neck,  etc. 
They  do  no  harm  at  all,  and  are  perfectly  good  ways 
to  kill  time  if  we  have  nothing  else  to  do. 

Q.  If  we  have  not  any  sterile  gauze,  can  we  use  anything 
that  is  clean  to  stop  hemorrhage? 

A.  Use  anything  that  is  clean  or  anything  that  is  not 
clean.  Sterile  gauze  first;  next  to  that  anything  that  is  clean ; 
next  to  that  anything  that  is  not  clean.  In  a  bleeding  wound 
the  current  is  away  from  the  body  and  the  germs  will  usually 
be  pushed  out.  The  gauze  is  a  great  deal  better  than  any 
other  material  because  of  its  mesh.  Cotton  or  linen  or  any- 
thing else  than  gauze  does  not  work  nearly  as  well. 

Hemorrhage  from  the  lungs,  bleeding  from  the  lungs, 
is  a  very  alarming  thing,  sometimes,  to  see.  The  first 
thing  to  remember  is  that  practically  no  one  ever  died 
from  hemorrhage  of  the  lungs.  It  looks  more  serious 
than  it  is.  It  is  a  symptom  of  pulmonary  tuberculosis, 
but  is  practically  never  fatal.  As  a  rule  the  patient  is 
not  any  worse  than  he  was  before.  There  is  nothing  the 
layman  can  do  about  it.  There  is  practically  nothing 
that  a  doctor  can  do  about  it,  and  as  a  rule  he  does 
nothing  but  tell  people  that  they  need  not  be  alarmed. 
The  trouble  often  is  made  worse  because  people  fly 
around  and  try  to  do  or  to  think  of  something  to  do. 
This  agitates  the  patient  and  aggravates  the  hemor- 
rhage. Keeping  as  quiet  as  we  can  is  the  main  thing 
that  makes  a  difference. 

The  same  thing  is  true  of  the  vomiting  of  blood  — 
practically  never  fatal  and  not  to  be  stopped  by  any 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

measure  that  is  known.  It  will  stop  itself.  We  know 
no  medicine  and  we  know  no  method  of  stopping 
hemorrhage  from  the  stomach.  There  is  a  certain 
amount  of  comfort  in  being  sure  that,  while  we  cannot 
do  anything,  no  one  else  can  do  any  more. 

Bleeding  from  the  bowel  is  very  common  in  connection 
with  hemorrhoids,  and  as  a  rule  does  no  harm.  Once 
in  a  great  while  we  see  a  person  who  loses  enough 
blood  to  get  anemic  and  exhausted.  That  is  a  very 
small  minority  of  cases.  The  patient  is  apt  to  think 
that  the  amount  of  blood  is  much  larger  than  it  is,  be- 
cause it  gets  mixed  with  water  and  it  is  hard  to  tell  how 
much  it  is.  But  there  is  no  need  in  nine  hundred  and 
ninety-nine  out  of  a  thousand  cases  of  being  in  the  least 
troubled  about  it. 

Perhaps  this  is  a  good  place  to  write  something 
about  hemorrhoids.  Hemorrhoids  are  practically  al- 
ways the  result  of  constipation,  and  will  not  stop  usu- 
ally until  the  constipation  stops.  Efficient  treatment 
of  constipation  will  often  stop  hemorrhoids.  Aside 
from  the  treatment  of  constipation,  the  other  impor- 
tant thing  is  to  keep  them  inside  the  body  instead  of 
outside.  The  hemorrhoid  is  a  dilated  or  plugged  vein  of 
the  same  nature  as  the  varicose  vein  on  the  leg.  When 
it  stays  outside  the  body,  it  very  easily  gets  irritated 
and  painful  and  may  suppurate.  But  although  people 
are  very  apt  to  think  they  cannot  keep  a  hemorrhoid 
back  inside  the  bowel,  they  practically  always  can  and 
practically  always  must.  If  they  do  that  and  also  at- 

482 


EMERGENCIES 

tend  to  the  matter  of  constipation,  as  a  rule  nothing 
else  is  needed  as  treatment.  If  those  means  do  not 
help,  there  are  ointments  to  be  obtained  from  any 
physician  which  will  help  somewhat,  and  if  those  do 
not  help  operation  is  a  last  resort.  But  it  is  not  always 
successful.  That  is,  if  the  same  cause  that  produces 
the  hemorrhoids  in  the  first  place  persists  —  consti- 
pation —  the  hemorrhoids  will  come  back  again,  no 
matter  how  thoroughly  they  are  operated  on  the  first 
time.  Piles  are  not  a  serious  matter,  then,  in  nine  hun- 
dred and  ninety-nine  cases  out  of  a  thousand,  and  not 
a  matter  needing  operation  if  the  simpler  methods  are 
attended  to. 

Cuts.  We  do  not  need  to  sew  up  a  cut ;  presumably 
we  should  not  expect  to ;  but  I  have  seen  conscientious 
people  who  thought  they  should  make  an  attempt  to 
sew  up  a  cut  if  the  doctor  was  not  at  hand.  The  worst 
that  can  happen  is  that  the  scar  will  be  a  little  larger 
than  if  it  were  sewn  up  at  once.  A  cut  sewn  up  very 
promptly  and  very  skilfully  leaves  a  smaller,  narrower 
scar.  If  it  is  not  sewn  up  at  all,  the  gash  fills  up  from 
the  bottom,  and  makes  a  wider  scar,  but  is  just  as 
satisfactory  a  healing  in  the  end. 

Bruises,  it  seems  to  me,  should  not  be  treated  at  all. 
It  is  not  incumbent  upon  us  to  try  to  think  of  any 
treatment  because  it  does  not  do  any  good.  I  do  not 
suppose  many  of  us  can  remember  the  days  of  vinegar 
and  brown  paper.  I  can  remember  vinegar  and  brown 
paper  being  put  on  bruises. 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

Sprains,  and  possible  fractures.  The  essential  thing 
for  laymen  is  to  do  nothing  at  all.  If  we  have  to  move 
the  person,  as  we  often  do,  the  best  thing  is,  I  think, 
something  I  have  already  mentioned  —  to  put  the  arm 
or  the  leg  lengthwise  on  a  pillow,  fold  the  sides  of  the 
pillow  over,  and  pin  them  with  safety  pins  across  the 
top.  That  makes  a  very  useful  splint.  One  can  take 
up  the  pillow  very  handily  and  one  does  not  hurt  the 
person  to  any  extent.  Nobody  who  is  conscientious  is 
certain  about  the  diagnosis  of  a  sprain  unless  there  has 
been  an  X-ray.  All  that  any  of  us,  even  physicians,  do 
nowadays  with  a  questionable  bad  sprain  or  fracture 
is  to  get  it  temporarily  done  up  and  take  it  to  an  X-ray 
machine. 

Loose  cartilages  in  the  knee-joint,  little  edges  or  bits 
of  the  cartilage  or  of  the  joint  membrane,  get  float- 
ing about  in  the  knee-joint.  Now  and  then  they  get 
pinched  between  the  bones,  the  upper  and  lower 
millstones  in  the  joint,  and  the  person  has  a  sudden 
catch  in  the  knee  and  a  sudden  pain.  He  slips  on  the 
floor,  or  in  football  or  in  tennis  has  a  sudden  sense  that 
something  is  very  wrong  in  the  knee.  In  the  great 
majority  of  cases  that  is  a  "loose  cartilage"  caught,  as 
I  have  said,  and  it  can  be  relieved  by  this  manoeuvre. 
Bend  the  knee  upas  far  as  it  will  go  and  then  straighten 
it  out.  Drawing  the  knee  up  opens  the  joint  on  one 
side,  and  allows  the  cartilage  to  get  out ;  then  straight- 
ening it  out  opens  the  other  side,  and  if  the  loose  body 
does  not  get  out  the  first  time,  it  may  the  second.  Gen- 

484 


EMERGENCIES 

erally,  when  we  do  this  the  patient  feels  something 
slip,  and  the  whole  thing  is  relieved. 

.  Unconsciousness,  whether  from  being  stunned  by  a 
blow,  or  from  fainting,  needs  no  treatment.  One  must 
repeat  a  great  many  times,  even  to  social  workers,  that 
there  is  no  danger  of 'people  dying  for  want  of  attention 
under  these  conditions.  We  may  hurry  them  back  to 
consciousness,  but  if  we  do  not  they  will  come  back 
just  the  same,  and  there  is  no  need  of  doing  anything 
at  all.  The  public  is  very  much  afraid  and  insists  on 
the  fact  that  So-and-So,  their  friend,  had  a  doctor 
"work  over  him  for  hours."  That  is  no  doubt  true, 
but  in  most  cases  the  patient  would  have  "come 
round"  just  the  same  if  nothing  had  been'  done. 
Fainting  does  not  mean  anything  wrong  in  the  person. 
Especially  it  does  not  mean  heart  disease.  People  with 
heart  disease  very  seldom  faint.  It  is  safe  for  them 
when  the  faint  is  over  to  get  up  and  go  about  their 
business. 

In  fits,  again,  we  are  safe  in  doing  nothing.  Nobody 
can  stop  a  fit  or  cure  it,  and  in  almost  every  case  the 
person  comes  out  of  it  without  any  permanent  dam- 
age. There  are  little  things  to  do,  which  I  think  I 
have  already  mentioned,  such  as  putting  cloth  or 
something  between  the  jaws  so  that  he  will  not  bite 
his  tongue.  But  even  if  we  fail  to  do  those  things  it 
does  not  make  any  special  difference.  The  worst  that 
can  happen  is  that  the  patient  will  have  a  sore  tongue 
the  next  day. 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

Convulsions  in  children  are  very  much  less  serious 
as  to  their  ultimate  significance  than  in  adults.  A  child 
often  has  convulsions  for  slight  reasons  connected  with 
his  digestion  or  his  teeth,  and  gets  over  them  and  is 
perfectly  well  for  the  rest  of  his  life.  The  one  thing 
that  we  can  safely  do  is  to  put  the  child  into  a  hot 
bath.  The  heat  does  shorten  convulsions  in  some  cases. 
If  it  does  not,  there  is  nothing  else  to  do. 

In  contrast  with  all  these  things,  there  is  one  disease 
in  which  what  we  do  makes  the  greatest  difference  and 
must  be  done  at  once;  that  is  sunstroke.  It  was  an  old 
by-word  in  the  Massachusetts  General  Hospital  that 
if  one  heard  the  medical  officer  running  there  must  be  a 
sunstroke  case  in  the  accident  room.  That  expresses 
what  I  mean  —  that  this  is  one  of  the  few  emergen- 
cies where  to  do  the  right  thing  and  to  do  it  at  once 
may  save  a  life.  Of  course  the  right  thing  at  first  is  to 
be  sure  what  disease  the  patient  has,  but  this  diagnosis 
depends  wholly  upon  two  facts  —  the  conditions  under 
which  the  patient  became  unconscious  and  the  tem- 
perature as  found  by  thermometer.  If  a  person  who 
has  been  working  in  the  sun,  and  has  been  perfectly 
well  up  to  that  time,  falls  unconscious  on  a  very  hot 
day,  especially  with  a  high  humidity,  and  if  his  tem- 
perature is  found  to  be  106°  or  more,  the  diagnosis  is 
so  near  certain  that  we  should  act  as  if  it  were  certain. 
The  temperatures  in  sunstroke  are  often  higher  than 
106°,  —  108°,  112°,  —  I  have  seen  115°.  It  is  very 
seldom  less  than  106°  when  the  patient  is  unconscious. 

486 


EMERGENCIES 

There  is  nothing  else  characteristic;  the  patient  is 
deeply  unconscious  and  that  is  all. 

The  treatment,  of  course,  is  to  bring  the  temperature 
down,  for  the  body  cannot  stand  that  temperature  for 
long,  —  and  the  way  to  do  that  is  to  use  ice.  The  pa- 
tient should  be  stripped  and  rubbed  with  ice.  Ordi- 
narily two  people  work  over  him,  each  with  a  block  of 
ice ;  one  rubs  the  upper  part  of  the  body  and  the  other 
the  lower  half,  first  back,  then  front.  We  keep  taking 
the  temperature  in  the  rectum  while  we  are  doing  this, 
and  when  the  temperature  gets  to  about  101°  we  stop 
the  ice,  for  the  cooling  process  keeps  on  after  we  have 
ceased  applying  the  ice  and  may  go  too  far.  We  gen- 
erally keep  a  cold  towel  or  ice-bag  on  his  head  as  well 
while  icing  the  body.  That  is  all.  Drugs  and  other 
methods  of  treatment  are  bad. 

We  can  do  the  same  thing  by  putting  the  person  into 
a  cold  bath,  but  any  one  who  has  dealt  with  an  uncon- 
scious adult  in  a  bath  knows  that  there  are  consider- 
able embarrassments  about  it;  we  do  not  want  to 
drown  him. 

He  generally  recovers  consciousness  within  twenty 
or  thirty  minutes,  and  as  a  rule  is  well  within  a  day  or 
two.  There  are  generally  no  permanent  ill  effects.  The 
people  that  we  hear  of  who  have  been  sick  ever  since 
they  had  a  sunstroke  are  generally  people  who  had 
something  else.  One  of  the  curious  things  about  sun- 
stroke is  that  it  does  not  happen  in  many  of  the  hottest 
places  in  the  arid  States  of  this  country,  where  they 

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A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

have  temperatures  such  as  we  never  have  in  the  East, 
but  without  our  high  humidity.  I  was  in  Arizona  when 
the  thermometer  was  at  120°,  but  the  doctors  of  the 
State  told  me  that  nobody  ever  had  a  sunstroke  in 
Arizona,  and  I  believe  that  is  true.  People  with  sun- 
stroke faint  right  away.  It  is  very  quick  as  a  rule;  a 
man  will  be  at  work  at  twelve  o'clock,  and  at  two 
minutes  past  twelve  he  will  be  unconscious.  He  may 
have  a  little  headache  before  it  comes,  but  generally 
not  enough  to  make  him  stop  work. 

Quite  different  is  heat  exhaustion.  Heat  exhaustion 
comes  to  people  working  indoors  out  of  the  sun  —  engi- 
neers, firemen.  The  patient  is  not  unconscious.  (The 
sunstroke  patient  is  always  unconscious.)  He  is  not 
hot ;  the  surface  of  the  body  is  cool ;  the  thermometer 
shows  that  he  has  no  fever.  He  is  very  weak  and  may 
die,  though  he  generally  does  not,  but  he  does  not  look 
at  all  like  a  sunstroke  patient  and  does  not  behave  like 
one.  Heat  exhaustion  is  a  form  of  cardiac  failure  due 
to  heat  and  to  the  conditions  of  work.  These  people 
need  simply  to  be  taken  out  of  the  heat  and  kept  quiet; 
they  do  not  need  any  ice  or  anything  else. 

Burns  can  be  treated,  if  we  have  the  material  at 
hand,  so  as  to  make  them  almost  painless.  When  I  was 
working  in  a  chemical  laboratory  once,  I  spilled  boiling 
sulphuric  acid  on  my  wrist.  When  cold  it  will  burn  the 
skin;  when  boiling  it  burns  very  rapidly.  I  happened 
to  be  close  to  a  faucet.  I  put  the  wrist  under  the  water, 
feeling  no  pain,  and  kept  it  there  until  somebody  found 

488 


EMERGENCIES 

the  next  thing;  which  is  bicarbonate  of  soda.  I  plas- 
tered that  on  and  never  had  any  pain  at  all,  although 
it  was  quite  a  deep  burn.  Get  the  burnt  part  under 
water,  in  the  first  place,  to  keep  the  air  off;  then  get  it 
into  alkali  which  should  be  plastered  on  and  covered 
with  a  moist  rag  to  keep  it  in  position.  When  a  burn 
has  been  exposed  to  the  air  for  some  time  before  we  get 
these  remedies  on,  they  do  not  do  so  much  good.  The 
quicker  we  can  get  them  on,  the  more  relief  from  pain. 
Later  a  burn  is  usually  dressed  with  some  ointment  in 
order  to  exclude  air  and  yet  prevent  the  dressings 
from  sticking. 

The  effects  of  cold,  frost  bite,  can  be  passed  over  very 
quickly.  If  a  person  freezes  his  ear  or  freezes  his  cheek, 
the  whole  point  is  not  to  allow  it  to  be  warmed  too 
quickly.  The  blood  is  all  driven  out,  and  if  the  full 
rush  of  blood  goes  back,  the  tissues  may  die ;  so  that 
we  try  to  warm  the  part  up  slowly.  We  have  all  heard 
about  rubbing  the  part  with  snow.  Of  course,  we  can- 
not rub  it  with  snow  for  more  than  a  minute  without 
its  getting  warmer.  A  cloth,  with  what  we  should 
ordinarily  call  cold  water,  put  over  the  frozen  ear  or 
cheek  of  a  person  in  a  fairly  warm  room,  will  keep  the 
part  from  getting  warm  too  quickly.  That  carries  out 
the  same  idea  as  rubbing  it  with  snow,  and  in  a  little 
more  rational  form. 

Poisoning  with  something  taken  into  the  stomach. 
The  first  aid  is  to  empty  the  stomach,  and  the  easiest 
way  to  empty  the  stomach  is  to  put  a  couple  of  heaping 

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A  LAYMAN'S  HANDBOOK  OF   MEDICINE 

teaspoonfuls  of  mustard  into  a  glass  of  water  and  get 
the  patient  to  swallow  it.  If  we  cannot  get  that, 
merely  large  draughts  of  lukewarm  water  will  make  a 
good  many  people  vomit,  and  if  it  does  not  it  will  dilute 
the  poison,  which  is  all  good  so  far  as  it  goes.  That  is 
about  as  much  as  it  is  worth  while  to  try  to  remember. 
The  one  thing  that  will  perhaps  stay  in  our  minds  is 
the  acid-alkali  contrast.  If  the  person  has  taken  acid 
we  give  him  an  alkali.  Alkali  is  soda;  acid  is  vinegar 
or  lemon  juice.  If  he  has  taken  alkali,  he  can  be  helped 
to  some  extent  by  pouring  down  a  weak  acid  on  top. 
Emptying  the  stomach  is  a  safe  and  proper  thing  for 
anybody  to  do. 

I  can  remember  being  told  all  sorts  of  things  about 
what  we  ought  to  do  for  snake  poison,  but  I  should 
advise  laymen  not  to  try  to  remember  anything  about 
it.  The  chances  are  we  shall  never  see  it. 

Drowning.  There  are  a  good  many  things  to  be  done 
here,  and  it  is  important  to  do  them.  The  best  way  to 
remember  them,  I  think,  is  to  have  a  clear  idea  of  what 
it  is  we  are  trying  to  remedy.  A  person  who  is  near  to 
drowning  is  a  person  who  has  got  water  into  his  lungs 
—  taken  water  into  the  lungs  down  his  windpipe,  and 
who  has  stopped  breathing.  Those  are  the  two  essen- 
tial facts.  We  never  should  fail  to  attempt  resuscita- 
tion, no  matter  how  dead  he  seems. 

It  is  quite  easy  to  see  what  we  ought  to  do  and  if  we 
have  somebody  to  help  us  it  is  quite  easy  to  do.  Stand 
the  person  on  his  head.  As  a  rule  there  is  more  than 

490 


EMERGENCIES 

one  person  at  hand,  and  two  people  can  lift  the  body 
up  and  hold  it  head  downwards.  That  is  all  that  is 
necessary  as  a  rule  in  order  to  get  the  water  out.  Some- 
times we  put  the  patient  across  a  bed  or  a  table,  with 
his  head  hanging  down,  which  is  nearly  as  effective  as 
the  other  position  and  much  easier. 

Get  the  water  out.  That  is  the  first  thing  which  has 
to  be  done.  The  remaining  things  are  both  to  be  done 
at  once.  One  is  to  get  the  patient's  body  warm,  for  it 
is  very  cold ;  and  the  other  is  to  make  him  breathe.  We 
take  off  his  clothes  and  get  hot  blankets  next  to  his 
skin  if  we  can.  That  makes  a  difference,  although  it  is 
not  the  main  thing. 

Q.  If  you  do  not  get  the  water  out,  how  long  do  you  want 
to  keep  him  in  the  inverted  position? 

A.  The  water,  or  all  that  we  get  out  will  run  out  of  his 
mouth  at  once  —  there  is  nothing  to  keep  it  in  if  he  is  upside 
down. 

Q.  Is  it  any  use  to  roll  a  patient  on  a  barrel? 

A.  The  idea  of  that  is  that  if  the  patient  is  lying  face 
downward  across  a  barrel,  with  his  legs  on  one  side  of  it  and 
his  head  on  the  other,  he  will  be  in  the  right  position  for  the 
water  to  run  out  of  his  lungs.  A  fence,  a  table,  a  bed,  will  do 
just  as  well. 

There  remains  the  essential  treatment  which  is 
called  "artificial  breathing."  What  opens  a  person's 
chest  and  what  closes  it?  We  wish  mechanically  to  pull 
the  chest  open  as  it  is  opened  by  a  deep  breath.  We 
have  two  convenient  handles,  the  arms,  by  means  of 
which  we  can  pull  open  his  chest.  The  easiest  way,  it 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

seems  to  me,  if  we  are  alone,  is  to  have  the  person  lying 
on  his  back  on  the  floor  or  ground,  then  stand  at  his 
head,  get  hold  of  his  arms,  and  pull  them  up  above  his 
head  until  the  elbows  nearly  meet.  That  opens  the 
chest.  The  arms  are  joined  to  the  chest  so  that  we 
cannot  pull  them  up  without  opening  the  chest. 

As  soon  as  we  have  got  the  arms  up,  we  put  them 
down  again  and  then  lean  on  the  chest  pressing  its 
sides  down  and  in  so  as  to  push  the  air  out  of  it.  We  do 
this  about  as  often  as  we  breathe  ourselves  (eighteen 
to  the  minute  is  the  average).  That  rhythm  must  be 
kept  up  until  the  patient  begins  to  breathe  himself,  — 
for  hours  if  necessary.  There  are  well-recorded  cases 
where  the  patient  has  not  breathed  of  himself  until 
after  an  hour  of  continuous  pumping  of  the  kind  de- 
scribed. What  we  hope  is  that  after  we  have  done  arti- 
ficial respiration  for  a  few  minutes  the  patient  will 
start  and  breathe  himself.  But  he  often  does  not  for  a 
long  time,  and  we  should  never  give  up  for  at  least  an 
hour. 

It  is  best  not  to  try  to  find  out  whether  the  heart  has 
stopped  or  not.  We  are  doing  the  best  we  can  by  carry- 
ing out  artificial  respiration  and  keeping  the  patient 
warm,  after  we  have  got  the  water  out  of  his  lungs. 
There  are  various  ways  of  doing  artificial  respira- 
tion, but  I  think  if  we  master  this  one  it  will  be  suffi- 
cient. 

Bee  sting.  We  all  know  the  traditional  advice,  to 
put  some  mud  on  it.  I  suppose  the  reason  mud  is  ad- 

492 


PERSONAL  HYGIENE 

vised  is  that  mud  is  often  alkaline  and  pretty  nearly  all 
bee  stings  are  acid  —  but  it  does  not  seem  to  me  per- 
sonally that  it  makes  a  great  deal  of  difference  what 
we  do. 

Q.  How  can  we  tell  a  faint  from  a  heart  failure? 

A.  We  cannot.  We  have  to  have  a  doctor  for  that.  In  the 
vast  majority  of  cases  the  patient  will  come  to  in  a  short 
time,  and  then  we  know.  The  other  thing  to  remember  is 
that  people  with  heart  failure  do  not  generally  become  un- 
conscious, but  usually  breathe  very  hard  like  a  person  at  the 
end  of  a  race.  If  it  happened  that  a  person  became  uncon- 
scious from  heart  disease,  no  one  but  a  doctor  could  tell  it. 

Home  Medicine 

People  used  to  have  good,  well-stocked  medicine 
closets  at  home,  but  one  of  the  best  signs  of  the  time, 
I  think,  is  that  medicine  closets  are  disappearing. 
Gauze  is  a  very  essential  thing  to  have.  But  we  do  not 
need  to  have  brandy,  for  instance,  or  whiskey,  or  any 
"stimulant"  at  hand.  There  is  no  occasion  for  those 
drinks  in  medicine.  Any  one  who  needs  a  stimulant 
had  better  have  coffee,  or  hot  milk,  or  hot  soup.  I  do 
not  really  know  a  single  medicine  that  I  think  is  neces- 
sary to  keep  in  stock  in  a  house. 

Personal  Hygiene 

Sleep.  Sleep  all  that  you  can.  You  cannot  overdo  it 
and  should  go  to  bed  early  enough  to  have  slept  your 
sleep  out  and  prefer  to  get  up  when  your  natural  time 
for  rising  comes.  There  is  no  fixed  dose  of  sleep  for  all 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

persons.  Children  need  most,  old  people  least.  Each 
individual  should  find  out  his  own  proper  allowance 
and  get  it  regularly,  or  if  anything  shortens  it,  make 
up  what  is  lost.  Few  adults  need  less  than  eight  hours. 
Many  need  nine  or  ten. 

The  air  of  the  sleeping-room  should  feel  distinctly 
cool  and  should  be  in  motion.  Have  the  bed  near 
enough  to  the  window  and  the  window  (or  windows) 
open  enough  to  accomplish  these  two  objects.  In 
summer  cool,  moving  air  can  often  be  best  attained  by 
sleeping  outdoors.  In  winter  the  same  conditions  are 
easy  to  get  within  doors,  and  the  difficulty  of  keeping 
warm  and  quiet  is  much  more  easily  surmounted. 
Sleeping  indoors  is  better  than  wakefulness  outdoors. 

One  should  have  enough  covering  to  keep  warm :  no 
more.  If  there  is  difficulty  in  keeping  the  feet  warm,  a 
hot- water  bottle  should  be  used  without  hesitation  and 
habitually. 

The  quality  of  the  night  depends  on  the  quality  of  the 
day.  Routine,  peaceful  activity  of  mind  and  body, 
outdoor  air,  and  exercise  make  for  good  sleep.  Daily 
emotional  strains,  such  as  worry,  discontent,  remorse, 
fear,  anger,  excitement,  upset  the  night  as  well.  Idle- 
ness, and  especially  the  life  of  the  rich  female  loafer, 
prepares  for  bad  nights. 

The  hardest  work  should  be  done  in  the  morning  and 
the  easiest  in  the  evening.  So  far  as  I  know  there  are 
no  exceptions  to  this  rule,  though  many  falsely  treat 
themselves  as  exceptions.  If  we  are  to  sleep  well,  the 

494 


PERSONAL  HYGIENE 

daily  activities  should  steadily  taper  off  as  night 
approaches. 

Late  sleep,  begun  after  1 1  P.M.,  is  apt  to  be  short  sleep. 
This  is  probably  the  truth  in  the  old  traditions  about 
"beauty  sleep."  Sleep  begun  at  a  reasonably  early 
hour  is  more  likely  to  be  sufficient  in  amount  and  less 
likely  to  follow  an  over-active  evening. 

There  is  nothing  to  be  said  about  beds  or  coverings 
except  that  they  should  be  comfortable.  The  occa- 
sional sufferer  from  "feather  asthma'*  must,  of  course, 
avoid  feather  pillows  and  feather  mattresses. 

Individual  experience  must  determine  for  each 
whether  the  evening  meal  is  to  be  light  or  heavy.  No 
rule  can  be  made  about  it. 

Sleep  may  be  prolonged  after  the  morning  light 
comes  in  by  tying  over  the  eyes  a  black  silk  cloth  or  a 
black  stocking  the  instant  one  first  wakes,  at  or  near 
daybreak.  This  excludes  light  and  provides  the  condi- 
tions of  a  dark,  cloudy  morning  on  which,  as  we  all 
know,  people  tend  to  sleep  longer.  This  manoeuvre 
can  be  learned  within  a  week  so  that  we  fall  asleep 
again  almost  instantaneously  when  the  eye  covering  is 
in  place.  Such  covering  enables  us  to  keep  blinds  and 
curtains  wide  open  and  so  to  get  the  maximum  of  air 
circulation.  In  sleeping  outdoors  or  in  the  daytime, 
such  an  eye  covering  is  doubly  useful. 

Those  who  fall  asleep  promptly  enough,  but  wake 
early,  can  often  get  to  sleep  again  if  they  have  a  ther- 
mos bottle  with  hot  liquid  food  (soup,  malted  milk)  at 

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A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

the  bedside,  so  that  a  cupful,  with  a  cracker,  may  be 
taken  without  getting  up  when  they  wake. 

Insomnia  is  not  merely  wakefulness,  but  wakefulness 
plus  worry.  Exclude  the  latter  and  one  may  be  awake 
a  good  deal  and  yet  do  one's  work  and  keep  well.  If 
you  do  not  sleep  well,  never  allow  family  or  friends  to 
question  you  about  it  in  the  morning.  Take  all  rea- 
sonable measures  against  poor  sleep,  but  keep  it  secret 
and  never  use  drugs. 

Food.  Adults  generally  know  about  what  foods 
agree  and  what  disagree  with  them.  If  they  follow 
this  knowledge,  they  rarely  go  wrong.  As  we  grow 
older  we  need  less  food,  especially  less  meat,  and 
this  fact  often  mirrors  itself  in  lessened  appetite  for 
meat. 

The  quantity  of  food  can  usually  be  settled  by  one's 
appetite,  aided  by  two  other  observations:  (a)  one 
should  not  eat  enough  to  feel  sleepy  and  heavy  after 
meals,  and  (b)  one  should  try  to  keep  one's  weight  near 
to  what  is  ''normal"  (i.e.,  the  average)  for  one's 
height.  Any  one  noting  in  himself  a  tendency  to  exceed 
this  "normal"  should  eat  less  than  he  wants.  Any  one 
tending  to  fall  below  the  normal  should  try  to  keep  up 
his  weight  by  eating  more  than  thrice  daily  or  by  tak- 
ing milk  with  his  meals. 

Some  individuals  do  better  with  no  midday  meal  or 
with  practically  no  breakfast.  This  has  to  be  found 
out  by  each  through  experiment. 

Eating  alone  or  when  very  tired  does  not  suit  many 

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people.  Pleasant  company  at  meals  and  a  good  rest 
before  meals  are  a  great  advantage. 

No  meal  should  occupy  less  than  half  an  hour.  The 
chief  meal  of  the  day  should  have  an  hour  for  itself. 
Hurry  at  meals  and  "perpendicular  eating"  at  a  lunch 
counter  are  bad. 

Further  details  on  diet  are  given  on  pages  1 1 1  to  131. 
Regular  bowel  movements  should  be  made  habitual  by 
care  and  practice.  One  movement  a  day  is  the  average. 
Two  a  day  or  one  in  two  days  suit  some  people. 

Exercise.  The  vast  majority  of  healthy  people  take 
no  exercise  beyond  what  they  get  in  daily  work.  Those 
confined  to  a  desk  or  engaged  in  any  especially  seden- 
tary work  usually  need  to  even  up  the  balance  by  doing 
prescribed  muscular  work  of  some  kind,  if  they  are  to 
keep  well.  The  essentials  of  daily  exercise  are  (a)  that 
it  should  produce  fatigue,  but  no  more  than  an  hour's 
rest  will  recoup ;  (b)  that  it  should  make  us  sweat  and 
breathe  deeply;  (c)  that  it  should  be  enjoyable,  and  so 
make  us  forget  our  other  occupations;  (d)  that  it 
should  be  done  in  fresh  air  (cool,  moving,  free  of 
smells). 

Walking  will  do  all  this  for  some.  For  many  others 
walking  is  not  absorbing  or  enjoyable  enough  to  expel 
the  usual  train  of  thoughts.  Then  some  game  or  other 
form  of  exercise  is  needed.  Gymnasium  work  seldom 
secures  the  essential  fresh  air.  Most  gymnasiums  are 
hot  and  smell  when  many  persons  are  exercising  there. 

Gymnastics  done  before  breakfast  seem  to  help  some 

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people  to  feel  more  vigorous,  but  for  most  the  availa- 
ble period  is  too  brief  and  the  exercises  too  boresome  to 
be  of  much  value.  Golf  has  solved  the  problem  for  many 
of  the  well-to-do,  except  during  winter  months.  Skat- 
ing in  rinks  fills  a  place  in  the  difficult  winter  period. 
Dancing  would  be  ideal  did  it  not  involve  late  evening 
hours  and  bad  air.  Even  with  these  drawbacks  it  is 
certainly  of  value  as  exercise  as  well  as  recreation. 
Basket-ball  and  tennis — especially  doubles — are  fine 
for  those  who  can  get  them.  Singles  are  often  too  vio- 
lent for  the  middle-aged  who  especially  need  exercise. 

Bathing.  A  certain  portion  of  mankind  feels  the 
better  for  a  daily  cold  morning  bath  and  is  apt  to  feel 
an  almost  religious  enthusiasm  about  it.  Another  por- 
tion feels  distinctly  the  worse  for  a  cold  bath  before 
breakfast  or  finds  it  merely  a  bore.  Such  persons  are 
compelled  by  no  warrant  of  science  to  imitate  their 
enthusiastic  neighbors.  There  is  no  medical  authority 
for  the  daily  cold  bath  for  every  one.  The  shock  of  cold 
water  seems  to  start  some  people's  machinery  in  a 
useful  and  agreeable  way.  But  it  has,  of  course,  no 
important  connection  with  cleanliness,  for  which  warm 
or  hot  baths  are  best. 

Bodily  cleanliness  is  chiefly  a  matter  of  comfort  or 
pleasure,  not  of  health.  With  some  it  has  moral  or 
spiritual  associations  which  make  it  a  symbol  of  value, 
and  such  people  are  often  doggedly  determined  to  be- 
lieve in  its  hygienic  value.  But  I  can  find  no  scientific 
warrant  for  such  belief.  Persons  and  races  that  never 

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bathe  are  among  the  healthiest  of  mankind.  Skin  in- 
fections are  in  some  people  warded  off  by  cleanliness. 
In  others  it  has  no  such  effect. 

To  wash  the  hands  before  eating  has  a  known  value 
for  health  in  those  whose  occupations  soil  their  hands 
with  septic  or  poisonous  material  —  e.g.,  painters, 
butchers  —  and  is  a  good  general  precaution. 

In  civilized  communities  a  certain  degree  of  clean- 
liness has  a  social  value.  It  prevents  our  being  un- 
pleasant to  our  neighbor's  nostrils  and  to  his  eyes.  Its 
industrial  value  to  those  who  seek  to  get  or  to  hold  a 
job  is  also  considerable.  To  those  who  cannot  feel  self- 
respect  unless  they  have  reached  a  certain  standard 
of  cleanliness,  it  has  undoubted  moral  value.  But  it 
should  be  realized  that  this  standard  is  quite  arbitrary. 
A  frequency  of  bathing  sufficient  to  make  A  "feel  clean 
and  self-respecting"  is  wholly  insufficient  for  B  and 
superfluous  for  C.  A  lady's  hands  cleansed  and  mani- 
cured for  a  social  function  would  be  quite  filthy  from  a 
surgeon's  standpoint,  and  even  he,  after  all  his  anti- 
septics, bears  germs  innumerable  beneath  the  surface 
of  his  skin.  The  sensible  person  adopts  an  arbitrary 
standard  which  suits  his  own  and  his  neighbor's  tastes. 

Sea-bathing  at  the  time  of  the  menstrual  period  has 
been  frowned  on  by  many,  but  apparently  without 
warrant.  Indeed,  some  eminent  gynecologists  hold 
that  the  menstrual  function  is  benefited  by  sea-bathing 
during  menses. 

As  to  clothing  comfort  and  respectability  rather  than 

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hygiene  should  be  our  guide.  There  is,  for  most,  no 
other  rule.  Special  fabrics  have  no  merit  beyond  their 
comfort. 

Innumerable  hygienic  superstitions  gather  about  the 
subject  of  changes  in  clothing  at  different  seasons. 
Some  will  not  be  persuaded  to  wear  light  clothes  on 
the  occasional  hot  days  in  winter.  For  such  prejudices 
there  is,  so  far  as  I  know,  no  scientific  warrant.  Cus- 
tom and  habit  rule. 

Most  healthy  persons  can  exercise  till  sweat  runs 
free  and  then  plunge  at  once  into  cold  water  with  great 
refreshment  and  no  ill  effects.  To  face  cold  air  in 
scanty  clothing  when  hot  from  dancing  is  likewise 
harmless  for  most.  "Colds"  are  rarely  caught  from 
cold,  and  draughts  are  usually  beneficial.  To  get  one's 
clothes  wet  or  one's  feet  wet  is  ordinarily  quite  harm- 
less unless  one  gets  chilled  and  stays  so  for  a  period 
sufficient  to  drain  one's  vitality.  To  shiver  for  hours 
at  a  football  game  —  wet  or  dry  —  is  doubtless  to  put 
some  strain  upon  one's  reserves  of  strength.  If  these 
are  at  a  low  ebb,  disease  may  result.  But  merely  to  be 
wet  in  this  or  that  part  of  one's  body  has  no  known  ill 
effects  or  evil  tendencies  for  health. 

Menstruation.  Here,  as  in  all  departments  of  hy- 
giene, individuality  plays  a  leading  part.  Some  women 
feel  no  depression  and  no  need  to  limit  their  activity 
during  the  menses.  Some  must  absolutely  give  up  and 
go  to  bed  for  a  day  or  more.  But  these  extremes  are 
rare.  The  great  majority  of  women  get  on  best  if  they 

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restrict  exercise  and  mental  effort  in  a  moderate  degree, 
and  especially  on  the  first  day.  I  have  known  many 
women  who  kept  too  quiet  at  the  menses  and  were 
better,  both  in  mind  and  in  body,  when  they  went 
about  more  and  did  more  than  had  previously  been 
their  wont.  Self-centredness  and  morbid  self-absorp- 
tion is  favored  by  entire  quiet  at  the  menses  and 
psychoneurotic  states  grow  up  easily  under  such 
conditions. 

I  remember  a  girl  who  always  had  pain  at  her  menses 
until  a  sudden  change  in  family  finances  obliged  her  to 
earn  her  living  as  a  secretary.  Soon  after  this  change 
all  menstrual  pain  left  her. 

Moderate  restriction,  not  abolition  of  normal  activi- 
ties, is,  then,  the  best  rule  for  the  great  majority. 

The  menopause,  the  cessation  of  menstruation  in 
women  at  or  near  the  fiftieth  year  is  usually  accompa- 
nied by  changes  in  the  circulation  described  as  "hot 
flushes  "  and  felt  chiefly  in  the  head.  There  is  no  rea- 
son to  dread  the  period  as  many  have  been  taught  to 
do  and  no  especial  danger  of  insanity  or  any  other  dis- 
ease at  this  time.  The  best  hygiene  is  to  pay  no  at- 
tention to  the  menopause. 

Rest,  recreation,  vacation.  Besides  our  nightly  repose 
we  are  certainly  the  better  for  one  day's  rest  in  seven, 
and  this  day  should  be  stretched  to  a  day  and  a  half  by 
the  addition  of  Saturday  afternoons.  To  use  up  these 
spare  times  with  chores  or  odds  and  ends  can  hardly 
be  best  for  many. 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

On  Sundays  most  of  us  should  supplement  our  week- 
day's scanty  allowance  of  exercise,  fresh  air,  recrea- 
tion, friendship,  family  life,  and  religious  refreshment. 
No  one  defends  the  popular  Sunday  habit  of  gorging 
and  dosing  with  or  without  the  narcotics  of  Sunday 
newspapers. 

Most  people  need  a  vacation  annually  or  oftener  — 
not  only  for  rest  but  for  change  and  reorientation. 
Mothers  of  families  need  such  a  change  fully  as  much 
as  their  husbands,  but  often  do  not  get  it.  The  opti- 
mum vacation  for  most  people  is  somewhere  in  the 
vicinity  of  four  continuous  weeks  annually.  School- 
teachers with  three  months'  holidays  often  have  too 
much  of  it  and  are  poorly  at  the  end.  When  school 
begins  again  and  the  harness  of  routine  is  resumed, 
their  health  and  spirits  often  rise  amazingly. 

On  the  other  hand,  a  week  or  two  is  often  quite 
insufficient  to  make  up  for  the  wear  and  tear  of  the 
year  and  even  a  month  is  not  always  enough.  The 
ideal  vacation  includes  a  complete  change  of  scene  and 
an  enjoyable  change  of  ideas  and  occupation.  Abso- 
lute idleness  is  beneficial  to  very  few  and  many  are 
distinctly  the  worse  for  it.  The  "weight  of  chance 
desires"  and  empty  hours  is  burdensome  and  some 
sort  of  routine  is  usually  pleasant  even  in  vacation. 

A  hobby,  an  avocation,  something  other  than  one's 
regular  work,  is  necessary  for  almost  all  of  us  if  we  are 
to  avoid  "going  stale"  in  mind  and  body.  The  con- 
tinuous use  of  one  set  of  mental  and  bodily  activities 

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year  in  and  year  out,  is  stultifying  and  wearisome.  An 
avocation  should  grow  up  early  in  life.  It  is  hard  — 
though  sometimes  painfully  necessary  —  to  cultivate 
one  late  in  life. 

The  main  qualifications  for  a  good  hobby  are  that  it 
should  be  enjoyable  and  should  make  us  forget  our 
workaday  selves.  It  is  well  also  if  it  is  something  that 
can  be  carried  on  when  our  working  strength  abates  or 
fails.  Most  Americans  are  utterly  unprepared  to  "re- 
tire" from  business  and  do  not  know  how  to  grow  old. 
Music,  reading,  chess  are  examples  of  avocations  which 
can  be  continued  after  our  working  days  are  over. 


CHAPTER  XX 

MISCELLANEOUS   AILMENTS,    TRIVIAL   OR   SEVERE 

Common  colds.  Infection  of  the  nose,  throat,  and 
upper  air  passages  is  caused  by  many  kinds  of  bacteria, 
and  if  it  is  relatively  mild  it  is  sometimes  called  a  com- 
mon cold.  It  is  undoubtedly  contagious,  and  much 
trouble  might  be  saved  if  people  with  colds  would  keep 
away  from  their  neighbors.  Such  isolation  is  almost 
the  only  thing  of  importance  in  the  management  of  the 
disease.  If  there  is  fever  with  it,  the  patient  should 
remain  quietly  at  home,  but  it  is  rarely  necessary  to  go 
to  bed.  We  know  no  way  to  shorten  the  course  of  the 
disease,  but  it  is  certainly  wise  to  increase  our  allow- 
ance of  sleep  and  to  cut  down  on  all  forms  of  strenuous 
activity.  Drugs  do  not  seem  to  me  of  value. 

Vasomotor  rhinitis  is  the  sudden  appearance  of  a 
nasal  discharge,  with  or  without  sneezing.  This  is  akin 
to  hay  cold  but  comes  at  all  seasons.  The  whole  thing 
may  disappear  within  a  few  hours.  It  is  not  a  germ 
disease  and  has  nothing  to  do  with  a  common  cold,  but 
for  the  layman  the  two  are  usually  quite  indistinguish- 
able. Remedies  taken  for  vasomotor  rhinitis  are  often 
given  credit — quite  falsely — for  having  cured  a  cold. 

Hang-nail  and  paronychia  are  manifestations  of 
lowered  vitality.  A  minute  slit  at  the  root  of  the  nail 
does  not  become  a  hang-nail  unless  it  gets  infected  by 

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bacteria.  This,  in  turn,  does  not  happen  unless  we  are 
below  par  physically.  It  is,  accordingly,  a  good  index 
of  general  condition  in  many  persons.  If  the  infection 
works  more  deeply  into  the  tissues  and  leads  to  pus  for- 
mation, we  call  it  paronychia.  The  latter  may  have  to 
be  cut  open,  but  it  many  cases  it  will  heal  itself,  like  a 
hang-nail,  if  the  patient  husbands  his  resources  of 
strength  by  taking  things  easy  and  increasing  his  al- 
lowance of  sleep. 

In-growing  toe  nail  is  usually  a  wrapping-over  of  the 
flesh  next  to  the  nail,  owing  to  pressure  of  the  shoe,  and 
does  not  come  to  our  notice  unless,  like  hang-nail,  it 
becomes  infected.  A  bit  of  surgeon's  plaster  drawn 
around  the  toe,  so  as  to  pull  back  the  flesh  from  the 
edge  of  the  nail,  is  often  sufficient  to  stop  the  trouble, 
provided  the  impinging  corner  of  the  nail  is  cut  habitu- 
ally short.  In  extreme  and  long  standing  cases  a  slight 
operation  may  have  to  be  done. 

Bursitis  over  the  shoulder  joint  is  the  usual  cause  of  a 
stiff  and  painful  shoulder,  with  difficulty  in  raising  the 
arm  above  the  head.  Even  a  slight  blow  upon  the 
shoulder  may  start  such  inflammation  of  the  bursa, 
which  is  a  little  lubrication-sac  between  the  head  of  the 
humerus  and  the  projecting  wing  of  the  shoulder  blade. 
Sometimes  such  inflammation  comes  without  any 
cause  that  we  can  find.  However  it  starts,  it  has  an 
astonishing  power  to  make  the  shoulder  muscles  waste 
away  and  to  cause  troublesome  disability  within  a 
short  time.  The  great  majority  of  cases  get  well  with- 

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out  any  surgical  interference,  but  it  often  takes  weeks 
of  painful  effort  to  win  back  the  use  of  the  shoulder 
muscles.  Patients  must  be  urged  to  attempt  the  mo- 
tions most  difficult  for  them  and  to  do  this  several 
times  a  day,  despite  pain. 

Shingles  is  a  disease  showing  itself  by  a  group  of 
water  blisters  and  sores,  usually  along  the  side  of  the 
chest,  occasionally  in  other  places.  It  is  a  manifesta- 
tion of  nerve-infection  and  follows  the  course  of  one  of 
the  nerves  which  run  between  the  ribs.  Distressing 
neuralgia  may  precede  or  accompany  it.  It  seems  to  be 
commoner  in  elderly  people.  Considerable  relief  from 
pain  may  be  had  by  freezing  the  skin  with  an  ethyl- 
chloride  spray  over  the  point  of  exit  of  the  affected 
nerve  from  the  spinal  cord. 

Chorea  or  St.  Vitus's  dance.  Though  something  has 
been  said  of  this  disease  in  an  earlier  chapter,  I  wish 
to  emphasize  here  certain  further  points.  It  is  a  germ 
disease,  due  to  the  same  streptococcus  which  produces 
rheumatism,  tonsillitis  and  heart  trouble  in  children. 
The  usual  age  is  from  five  to  eighteen.  It  is  a  self-lim- 
ited disease  and  runs  its  course  ordinarily  within  a  few 
weeks,  but  like  other  streptococcus  infections,  it  is 
prone  to  relapse. 

The  child  makes  restless  motions,  especially  of  the 
hands,  face,  and  feet,  and  is  apt  to  be  reproved  or  even 
punished  for  being  "fidgety."  Any  careful  observer, 
however,  would  notice  that  the  motions  are  beyond 
the  normal.  In  severe  cases  the  whole  body  may  be  in- 

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volved  and  even  sleep  may  give  no  respite.  The  child 
should  be  taken  out  of  school  and  in  all  severe  cases 
kept  quiet  in  bed.  Medicine  does  not  help. 

Chorea  should  be  distinguished  from  habitual  nerv- 
ous jerkings  of  the  face  or  other  parts,  known  to  neurol- 
ogists as  habit  spasm.  The  latter  lasts  for  life  and  is 
part  of  a  general  nervous  constitution.  It  has  nothing 
to  do  with  germ  disease  nor  with  heart  trouble.  Wink- 
ing and  grimacing  involuntarily  are  its  commonest 
manifestations  and  are  more  frequent  when  the  person 
is  tired  or  strained.  It  is  something  to  be  lived  down, 
not  treated. 

Hernia.  By  far  the  commonest  variety  occurs  in 
men  and  shows  itself  in  the  groin.  It  is  not  due  to  acci- 
dent and  should  not  be  called  rupture.  It  represents  a 
weak  spot  in  the  abdominal  wall,  present  from  birth, 
but  gradually  enlarging  with  age  and  labor  until  a  bit 
of  bowel  protrudes,  covered  only  by  the  skin.  In  mild 
cases  the  bowel  can  be  held  back  satisfactorily  with  a 
truss,  but  this  is  so  much  bother  that  operation  is  usu- 
ally advised,  especially  in  young,  strong  people.  The 
opening  is  sewn  up  tightly,  and  if  the  operation  is  well 
done  permanent  cure  results. 

Such  a  hernia  is  often  discovered  accidently  and  is 
then  referred  by  the  patient  to  some  recent  or  distant 
muscular  strain  which,  in  the  vast  majority  of  cases, 
can  only  aggravate,  more  or  less,  a  previously  existing 
hernia. 

Hernia  through  the  scar  occurs  after  operation,  when 

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the  incision  has  been  long  and  slow  to  heal.  The  bowel 
pushes  out  through  the  weakened  abdominal  wall.  The 
same  thing  may  happen  at  the  navel,  owing  to  con- 
genital laxity  and  weakness  of  the  parts. 

Any  hernia  which  is  not  kept  back  within  the  body 
may  get  nipped  or  twisted  ("strangulated")  with  the 
most  alarming  results.  Only  a  quick  and  skilful  opera- 
tion can  save  life.  The  symptoms  are  pain,  vomiting, 
and  abdominal  distention. 

Congenital  deformities  are  common  in  the  lip,  palate 
and  feet.  There  may  be  a  cleft  along  the  arch  of  the 
hard  palate  and  through  the  upper  lip  (hare-lip).  Both 
these  deformities  can  be  cured  by  an  early  and  skilful 
operation.  The  various  types  of  deformed  or  club- 
foot  should  be  treated  by  a  competent  orthopedic  sur- 
geon. A  good  deal  can  be  accomplished  by  operation 
and  apparatus,  but  more  or  less  lameness  generally 
remains. 

Enuresis  is  a  prolongation  into  youth  of  the  baby's 
natural  inability  to  control  his  urine.  Most  children 
learn  this  within  the  first  year  or  two  but  in  others, 
especially  of  a  neurotic  or  slightly  defective  type,  the 
control  is  not  acquired.  There  is  no  disease  of  the 
bladder  or  anywhere  else,  unless  it  be  of  the  brain,  — 
that  is,  a  greater  or  lesser  degree  of  feeblemindedness. 
Enuresis  is  especially  common  in  children  of  the  re- 
formatory type,  which  indicates,  I  suppose,  its  connec- 
tion with  congenital  weaknesses. 

Treatment  is  directed  to  the  establishment  of  con- 

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MISCELLANEOUS  AILMENTS 

trol  through  rousing  dormant  faculties.  In  the  milder 
types,  when  the  trouble  occurs  only  at  night,  it  can 
generally  be  cured  by  one  or  more  of  the  following  de- 
vices :  — 

(a)  The  child  should  never  drink  any  water  after 
6  P.M.  (b)  An  alarm  clock  set  for  the  hour  in  the  night 
In  which  a  child  generally  wets  the  bed,  or  for  a  time 
about  half  an  hour  previously,  can  be  arranged  so  as  to 
wake  the  child  up  and  have  him  get  up  and  pass  urine. 
(c)  An  ordinary  wooden  spool  can  be  fastened  with  a 
piece  of  tape  in  the  small  of  the  back,  the  tape  tied  round 
the  body  in  front.  This  makes  it  impossible  to  sleep 
comfortably  on  the  back,  but  gives  no  trouble  so  long 
as  the  child  sleeps  on  the  side.  Like  the  alarm  clock, 
the  spool  tends  to  make  the  child  subconsciously  aware 
that  there  is  something  which  he  should  look  out  about, 
and  trains  him  in  the  sort  of  auto-suggestion  out  of 
which  presumably  control  of  the  bladder  comes,  (d) 
Pumping  cold  water  upon  the  back,  up  and  down  the 
spine,  with  a  Johnson  pump,  for  five  minutes  just  at 
bedtime,  is  sometimes  effectual,  I  think  by  suggestion. 
(e)  The  same  holds  true  in  my  opinion  of  the  various 
operations  often  done  for  the  relief  of  enuresis.  Any 
operation,  such  as  tonsillectomy  or  circumcision,  makes 
a  strong  impression  upon  a  child's  mind,  especially  if  he 
is  made  to  understand  that  the  operation  occurs  be- 
cause of  his  enuresis.  (/)  Direct  moral  suasion  some- 
times has  an  effect,  especially  appeals  against  the  child- 
ishness of  bed-wetting  and  explanations  to  the  effect' 

509 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

that  as  one  grows  up  one  outgrows  this  sort  of  babyish 
action.  Medicines  have  not  seemed  to  me  effective, 
though  the  tincture  of  belladonna  is  often  given. 

Stammering  is  a  disease  not  of  the  mouth  or  throat 
but  of  the  brain  and  the  powers  of  control.  It  is  very 
catching  among  school  children,  and  any  one  with  an 
organism  predisposed  to  it  will  begin  to  stammer  if  he 
hears  others  around  him  doing  so. 

In  treatment  it  is  essential  that  the  child  should  be 
kept  away  from  others  who  stammer.  Beyond  that  he 
should  have  a  course  of  training  under  some  one  who 
has  given  special  attention  to  the  subject.  There  are 
many  methods  designed  to  overcome  stammering,  and 
most  of  them  are  successful.  But  it  is  most  important 
to  get  hold  of  the  trouble  in  early  life,  and  not  to  let 
the  habit  become  firmly  ingrained. 

Marasmus  is  a  term  still  used  by  specialists  in  chil- 
dren's diseases,  as  well  as  by  the  less  expert  members 
of  the  medical  profession,  to  indicate  an  extreme  de- 
gree of  malnutrition  without  discoverable  cause.  In- 
fantile atrophy  is  another  term  often  used  for  the  same 
condition.  Of  course  it  is  essential  to  distinguish  ma- 
rasmus from  the  emaciation  secondary  to  tuberculosis, 
syphilis,  or  gastro-intestinal  troubles. 

The  cause  of  the  disease  is  wholly  unknown,  and 
treatment  is  very  unsatisfactory. 

Still-birth.  The  term  is  applied  somewhat  loosely 
both  to  children  whose  death  has  evidently  occurred 
early  in  intra-uterine  life,  and  to  those  who  show  no 


MISCELLANEOUS  AILMENTS 

signs  of  life  at  the  time  they  are  born,  but  presumably 
have  not  been  long  dead.  Some  physicians  also  apply 
it  to  children  who  are  alive  at  birth  but  die  within  a 
few  hours  without  known  cause.  Syphilis  has  long  been 
supposed  to  be  the  most  important  cause  of  still-birth, 
but  there  are  certainly  many  cases  not  thus  to  be  ex- 
plained, and  not  satisfactorily  explained  at  all.  The 
nutrition  of  the  mother  during  pregnancy  doubtless 
plays  an  important  part,  as  still-births  are  much  com- 
moner in  badly  nourished  families. 

Starvation  is  a  condition  very  rarely  seen  in  this 
country  except  as  a  result  of  gastro-intestinal  disease. 
In  stowaways  aboard  ship  one  occasionally  sees  pitiful 
cases  of  starvation.  Doubtless  much  of  the  ill-health 
to  be  seen  among  the  poor  is  influenced  by  chronic 
malnutrition,  but  it  is  very  difficult  to  be  sure  upon 
this  point. 

In  true  starvation,  such  as  one  sees  in  a  stowaway, 
the  most  important  thing  is  to  prevent  the  individual 
from  eating  as  much  as  he  wants  to  when  first  he  gains 
access  to  food.  A  small  amount  of  liquid  nourishment 
should  be  allowed  every  hour  for  half  a  day,  then  grad- 
ually increasing  amounts  of  solid  food,  but  always 
under  the  directions  of  a  physician. 

Obesity  is  usually  a  congenital  tendency  rather  than 
a  result  of  overeating.  Fat  people  often  eat  less  than 
others.  Their  fat,  nevertheless,  burdens  them  like  any 
other  weight  that  we  have  to  carry.  It  is  a  strain  on  the 
heart  and  on  the  joints.  It  pushes  up  the  diaphragm 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE 

and  cramps  the  lungs.  It  makes  people  bear  operations 
badly  and  shortens  life. 

It  can  be  removed  by  getting  up  from  meals  before 
appetite  is  satisfied,  seldom  by  cutting  out  particular 
foods,  for  others  are  usually  eaten  in  excess  and  make 
up  the  balance.  Exercise  is  apt  to  increase  appetite 
and  so  to  make  dieting  harder.  Diet  is  therefore  the 
essential  thing  in  treatment. 

Cancer  has  been  referred  to  in  connection  with  the 
stomach,  the  gullet,  the  intestine,  and  the  uterus. 
Something  should  be  said  of  the  disease  in  other  parts 
of  the  body.  On  the  lower  lip  cancer  occurs  almost  ex- 
clusively in  those  who  smoke  a  pipe,  and  is  the  best 
example  of  the  part  which  is  played  by  chronic  irritation 
in  the  development  of  some  cancers  (though  not  of  all). 
On  the  lip  or  on  other  parts  of  the  face  cancer  is  a  rela- 
tively mild  and  slow-growing  disease,  permanently  and 
wholly  cured  in  most  cases  by  a  moderately  extensive 
operation.  It  shows  itself  as  a  harmless-looking  sore 
which  will  not  heal.  Any  such  sore  on  the  lip  or  near  the 
eye  should  always  be  examined  by  an  expert. 

Cancer  of  the  rectum  produces  rectal  pain  and  a  bloody 
discharge  with  diarrhea  or  alternating  diarrhea  and 
constipation,  usually  in  persons  past  middle  life.  The 
disease  is  sometimes  mistaken  for  piles.  Operation  is 
the  only  hope. 

Cancer  of  the  breast  produces  a  lump,  usually  painless, 
in  the  breast  of  a  woman  past  forty  —  occasionally  in 
earlier  years.  It  is  best  felt  by  pressing  the  breast  flat 

512 


MISCELLANEOUS  AILMENTS 

upon  the  ribs  with  the  palm.  Any  lump  in  a  woman's 
breast  should  be  shown  to  an  expert  for  diagnosis  as  soon 
as  it  is  discovered. 

Many  non-cancerous  lumps  in  younger  women  are 
now  removed  by  surgeons,  because  the  best-informed 
opinion  holds  that  about  ten  per  cent  of  them  later 
become  cancerous. 


THE   END 


INDEX 


Abdomen,  13. 
Abortion,  205,  207. 
Absorption  of  food,  31. 
Acetanilid    poisoning   from   head- 
ache powders,  411. 
Acne,  403,  449; 

in  adolescence,  450. 
Adenoids,  51. 
Adhesions,  191. 

Adulterants  mostly  harmless,  125. 
Agar  agar,  135. 
Air,  freshy  33; 

pure,  20. 
Alcohol,  always  a  narcotic,  416; 

relation  to  cirrhosis,  145. 
Alcoholism,  412-424; 

as  a  symptom  of  brain  disease, 

4H; 

treatment  of,  418; 

types  of,  412. 
Alkali,  100. 
Alum,  125. 

Alveoli  (air-pouches),  23. 
Amoebae,  88. 
Amoebic  dysentery,  147. 
Anaphylaxis,  351,  454. 
Anderson,  Victor  V.,  M.D.,  414. 
Anemia,  a  rare  disease,  296; 

causes  of,  297; 

pernicious,  298. 
Aneurism,  79. 
Angina  pectoris,  71; 

causes  for,  72. 
Anorexia  nervosa,  106. 
Anthrax,  398,  399. 
Anti-vaccination  cranks,  402. 
Antrum,  49; 

empyema  of  the,  51. 
Anus,  42. 
Aorta,  the,  16,  79. 
Aortic  arch,  15.  ^ 
Aortitis,  syphilitic,  79- 
Aphasia,  170,  257. 
Aphonia,  56; 

hysterical,  56. 


Apoplexy,  77,  256; 

or  cerebral  hemorrhage,  169. 
Appendicitis,  147,  149-153; 

acute,  151; 

causes  of,  149; 

chronic,  151; 

due  to  streptococci,  87. 
Appendix,  the,  28,  32. 
Aqueous  humor,  457. 
Arteries,  16. 

Arteriosclerosis,  62,  73,  75,  76,  284, 
466; 

in  the  heart,  78; 

of  the  brain,  77; 

of  the  kidney,  78; 

prognosis  of,  78; 

treatment  of,  78. 
Arthritis,  atrophic,  325,  329; 

deformans,  333; 

gonorrheal,  211,  326; 

gouty,  325; 

hypertrophic,  325,  327; 

infectious,  325; 

streptococcus,  325; 

traumatic,  325,  331; 

villous,  332. 

Artificial  breathing,  491. 
Ascites,  146. 
Asthma,  61. 
Astigmatism,  468. 
Atrophy,  infantile,  510. 
Avocation,  502. 

Bacteria  and  disease,  85.  4 

Basedow's  disease,  307. 

Bathing,  498. 

Beans,  food  value  of,  123. 

Bed-wetting,  508. 

Bee-sting,  492. 

Beef-tea,  123. 

Beri-beri,  127. 

Big  tonsils,  operations  for,  52. 

Bile,  34- 

Biliousness,  137. 

Birth-control,  214. 


515 


INDEX 


Bladder,  37,  42. 
Bladder,  stones  in,  179; 

symptoms  in  tuberculosis  of  kid- 
ney, 173; 

tumors  of,  179. 
"Bleeders,"  303. 
Bleeding,  control  of,  478. 
Blindness  in  chronic  Bright's  dis- 
ease, 1 68; 

in  acute  nephritis,  164. 
Blood,  diseases  of  the,  295-306; 

in  lead-poisoning,  409; 

poisoning,  389; 

pressure,  high,  77,  172; 

pressure,  causes  of  high,  72,  166; 

pressure,  high,  diet  in,  130; 

test  for  gonococcus  infection,  364; 

vomiting  of,  109,  481. 
Boils,  450. 

Bones    and    joints,    diseases    of, 
312-321; 

of  leg,  3; 

tuberculosis  of,  312. 
Bowel,  bleeding  from,  482 ; 

movements,  497. 
Bow-legs,  320. 
Brain,  45,  46; 

centers  in,  47; 

disease,  as  cause  of  dyspepsia, 
106; 

tumor,  258. 
Breast,  cancer  of,  512. 
Breathing,  deep,  20. 
Bright's  disease,  49,  466; 

disease,  causes  of,  161; 

disease,  chronic,  166; 

disease,  prognosis  in,  163; 

disease,  treatment  of,  165,  168; 

disease,  with  high  blood  pressure, 

166. 

Bronchi,  23. 
Bronchiectasis,  59. 
Bronchioles,  23. 
Bronchitis,  51,  57; 

acute,  57; 

chronic,  57,  58; 

wrong  diagnosis  of,  57; 
Bruises,  483. 
Bunions,  339. 
Burns,  488. 
Bursitis,  505. 


Caisson  disease,  439; 
symptoms  of,  441. 


Calory  value  of  food,  122; 
Cancer,  306,  512; 

of  bile-duct,  148; 

of  liver,  148; 

of  stomach,  95; 
«of  tongue,  92. 
Candy,  120. 
Cannon,  Dr.  Walter  B.,  116,  132, 

239- 

Capillaries,  16. 
Carbohydrates,  112,  113. 
Carbon  dioxide,  19. 
Carbuncle,  451. 
Caries  of  teeth,  86. 
Cartilages,  loose,  484. 
Castor  oil  for  diarrhea,  156. 
Cataract,  464. 
Catarrh,  54. 
Catarrhal  deafness,  473; 

jaundice,  148. 
Catheter  life,  213; 

use  of,  178. 

Cellulose,  115,  123,  128. 
Chancre,  369. 
Change  of  life,  200. 
Chaulmoogra  oil  for  leprosy,  402. 
Chemical  disease,  288. 
Chest,  13. 

Chicken-pox,  358,  403. 
Chlorosis,  301. 
Choking,  477. 
Chorea,  49,  506. 
Cirrhosis,  145; 

alcoholic,  108; 

vomiting  of  blood  in,  146. 
Cleanliness,  92,  499. 
Cleft  palate,  508. 
Clothing,  499. 
Club-foot,  508. 

Coal  dust  and  tuberculosis,  438, 
Cocaine,    a    habit-forming    drug, 
62; 

habit,  433. 
"Cold  abscess,"  313. 
Colds,  causes  of,  129; 

common,  500,  504. 
Colitis,  153. 
Colon,  29. 
Common  duct,  139. 
Compensation,  failing,  72. 
Compressed  air  disease,  439. 
Conjunctival  sac,  458. 
Conjunctivitis,  459. 
Consciousness,  dislocation  of,  103. 


516 


INDEX 


Constipation,  106,  128,  131,  132- 

137; 

a  mental  habit,  132; 

causes  of,  132. 

Contagion  time  in  scarlet  fever,  356. 
Convulsions,  486. 
Cornea,  457; 

ulceration  of,  459. 
Corneal  scars,  459. 
Coryza,  51. 

Coughs,  treatment  of,  59. 
Cretinism,  311. 
Curd,  tough,  115. 
Cuts,  483. 
Cystic  duct,  142. 
Cystitis,  178,  210. 
Cystocele,  195. 
Cystoscopy,  174. 

Deaf  mutes,  congenital,  476. 
Deafness,  causes  of,  476. 
Deformities,  congenital,  508. 
Delusion,  240; 

of  grandeur,  247; 

of  persecution,  249. 
Dementia,  243; 

arteriosclerotic,  248; 

paralytica,  245; 

precox,  239,  243; 

precox,  catatonic,  244; 

syphilitic,  245. 
Dental  fads,  87. 
Depressing  emotions  in  diabetes, 

294. 

Depression,  233. 
Dermatitis  venenata,  453. 
Diabetes,  288-295; 

treatment  of,  291. 
Diabetic  breads,  293; 

types,  290. 
Diaphragm,  13. 
Diarrhea,  153; 

in  tuberculosis,  157; 

treatment  of,  154. 
Diet,  111-132; 

guide  to,  117; 

in  rheumatism  and  kidney  trou- 
ble, 131; 

mathematics  of,  121. 
Dietary,  balanced,  113. 
Diphtheria,  161,  349; 

in  neuritis,  352. 

Disinfection  after  germ  diseases, 
355- 


Dizziness  of  arteriosclerosis,  78. 
Dropsy,  165. 

in  Bright 's  disease,  163. 
Drought,  20. 
Drowning,  490. 
Drugs,  107; 

producing  acne,  449. 
Duodenal  ulcer,  99. 
Duodenum,  28,  139. 
Dysentery,  154; 

amoebic,  154. 
Dyspepsia,  105; 

emotional,  103,  105; 

from  anemia,  no; 

from  heart  disease,  108; 

from  industrial  disease,  109; 

from  intestinal  disease,  109; 

from  kidney  disease,  109;  ^ 

from  liver  disease,  108. 
Dyspeptics,  chronic,  98. 

Ear,  diseases  of,  472-476; 

drum,  473. 
Earaches,  52. 
Eclampsia,  204; 

with  high  blood  pressure,  1 66. 
Eczema,  447,  448; 

from  varicose  veins,  81. 
Edsall,  Dr.  David  L.,  121 
Emergencies,  477~493- 
Emetin,  88. 

Emission,  nocturnal,  44. 
Emotional    disturbance    and    the 

intestine,  133. 
Emphysema,  62. 
Empyema,  63; 

post-pneumonia,  63; 

tuberculous,  64. 
Endocarditis,  68. 
Endocervicitis,  186. 
Endometritis,  185. 

hyperplastic,  186. 
Enteritis,  153. 
Enuresis,  508. 

Epididymis,  inflammation  of,  210. 
Epiglottis,  102. 
Epilepsy,  279-285; 

treatment  of,  282. 
Erosion  of  cervix,  186. 
Erysipelas,  394. 
Erythema,  447. 
Esophagoscope,  94. 
Esophagus,  the,  21,  93; 

corrosive  stricture  of,  94; 


517 


INDEX 


Esophagus  — 

spasmodic  stricture  of,  94. 
Eustachian  tube,  472. 
Excitement,  233. 
Exercise,  497; 

in  heart  disease,  74. 
Extensor  muscles,  12. 
Eye,  diseases  of,  457-472; 

muscles,  467; 

strain,  468. 

Fainting,  485. 
Fallopian  tube,  38. 
Far-sightedness,  469. 
Fatiguability,  pathological,  221. 
Fatigue,  130. 
Fats,  112,  128; 

in  diet,  123. 
Feces,  32.  * 
Feeble-mi ndedness,  253; 

results  of,  256. 
Fever,  typhoid,  349-359. 
Fevers,  long,  345. 
Fibroid  tumors  in  the  negro  race, 

182. 

Fibroids  in  pregnancy,  181. 
Fits,  485. 
Flat-foot,  338. 
Fletcherism,  118. 
Flexor  muscles,  12. 
Flies,  in  typhoid,  347. 
Floating  kidney,  172. 
Food,  496; 

bolting  of,  117; 

chewing  of,  116,  117; 

values,  E.  A.  Locke,  125. 
Foods,  breakfast,  124; 

classes  of,  112; 

fraud  in,  126; 

indigestible,  114; 

purity  of,  124; 

rich,  1 1 6. 

that  are  heating,  129. 
Forgetfulness    in    psychoneuroses, 

224. 

Fossa,  right  iliac,  150. 
Frost-bite,  489. 

Gall-bladder  disease,  due  to  strep- 
tococci, 87. 
Gall-stone  colic,  140. 
Gall-stones,  137-145; 

causative  factors  of,  143; 

dangers  of,  145. 


Gargling  the  throat,  51. 
Gastric  crises,  266; 

juice,  119; 

ulcer,  99. 
Gastritis,  101. 

Gastro-enterostomy,  96,  100. 
Generative  organs,  the,  38; 

organs,  female,  diseases  of  the, 
180-208; 

organs,  male,  42; 

organs,    male,   diseases  of   the, 

208-214. 
Glaucoma,  470. 
Glucose,  125. 
Glycogen,  35. 
Goitre,  exophthalmic,  307; 

non-toxic,  306; 

toxic,  307. 
Gonococcus  infections,  prevalence 

of,  364. 
Gonorrhea,  208,  361 ; 

cure  of,  2 1  L 
Gonorrheal  ophthalmia,  212,  362, 

459-.  . 

urethritis,  209. 
Gout,  330. 
Grand  mal,  279. 
Grape  sugar,  125. 
Graves's  disease,  307. 
"Ground  itch,"  344. 
Guinea  pig  test,  174,  175. 
Gullet,  the,  21,  26,  93. 
Gynecology,  193. 

Habit  spasm,  507. 

Habits,  130,  133. 

Hallucination,  240. 

Hang-nail,  504. 

Hare-lip,  508. 

Harrison  law,  428. 

Hay  fever,  62. 

Headaches,  468. 

Healy,  Dr.  William,  254,  280. 

Heart,  15; 

diseases  of  the,  67-76. 

disease,  arteriosclerotic,  70; 

disease,  arteriosclerotic,  progno- 
sis in,  71; 

disease,  compensation  in,  69; 

disease,  dropsy  in,  69; 

disease,  failure  of  compensation 
in,  69; 

disease,  in  childhood,  68; 

disease,  nephritic  type  of,  72; 


518 


INDEX 


Heart  — 

disease,  nervous  condition  in,  74; 

disease,  pain  in,  67; 

disease,  prognosis  of,  67,  73; 

disease,  rest  in  bed  in,  75; 

disease,  rheumatic,  68; 

disease,  short  breath  in,  69; 

disease,  symptoms  of,  67; 

disease,  syphilitic,  70; 

disease,  treatment  of,  73; 

disease,  types  of,  67; 

hypertrophy  of,  70; 

pain,  71. 
Heat  and  cold,  diseases  due  to,  443 ; 

exhaustion,  488. 
Heberden's  nodes,  328. 
Hematocele,  214. 
Hematuria,  179. 
Hemiplegia,  169,  257. 
Hemophilia,  303. 
Hemorrhage,  479; 

cerebral,  77; 

from  the  lungs,  481. 
Hemorrhoids,  136,  482. 
Hepatic  duct,  139. 
Hernia,  507. 

strangulated,  158. 
Heroin  habit,  60. 
Hip  disease,  312; 

disease,  "old  man's,"  328. 
History  in  cancer  of  stomach,  95; 

of  peptic  ulcer,  97. 
"Hives,"  454. 
Hookworm,  342-344. 
Hunchback,  315. 
Hydatid,  147. 

Hydrochloric  acid  in  stomach,  30. 
Hymen,  188. 
Hypermetropia,  469. 
Hyperthyroidism,  307. 
Hysterectomy,  182. 
Hysteria,  226. 
Hysteric  type,  222. 
Hysterical  fainting,  226. 

Idiot,  253. 

Impetigo,  451. 

Industrial  diseases,  435-447; 

fallacies  about,  435; 

fatigue,  no; 

overstrain,  446. 
Infantile  paralysis,  273. 
Infections   through   hair   follicles, 
399- 


In-growing  toe  nail,  505. 
Insanity,  242; 

alcoholic,  251; 

causes  of,  252; 

chronic,  in  arteriosclerosis,  77; 

circular,  234. 
Insomnia,  496. 
Intestinal  obstruction,  157; 

obstruction,  due  to  cancer,  159. 
Intestine,  diseases  of,  149-160; 

inflammation  of,  153; 

large,  28,  31; 

small,  28. 
Intubation,  351. 
Invalidism  in  women,  191. 
Iodide  of  potassium,  60. 
Iris,  457. 
Iritis,  atropin  in,  463;  , 

streptococcic,  462; 

syphilitic,  462. 
"Itch,"  453. 
Ivy  poison,  453. 

Jaundice,  142; 
catarrhal,  148. 

Keratitis,  interstitial,  461.] 
Kidney,  36. 

diseases  of,  161-178; 

tuberculosis  of,  173. 
K.I,  uses  of,  61. 
Knee-jerks,  loss  of,  267. 

Lacerations,  187. 
Laryngitis,  51,  55. 
Larynx,  21,  55. 
Laxatives,  134,  135.  ^ 
Lead,  as  cause  of  Bright's  disease, 
162; 

colic,  409; 

poisoning,  109,  407; 

poisoning  from  drinking  water, 
408; 

poisoning  in  painters  and  rubber 

workers,  408. 
Leprosy,  400. 
Leucemia,  302. 
Leucocytes,  50. 
Leucytosis,  152. 
Lightning  pains,  266. 
Liver,  34; 

abscess,  causes  of,  147; 

a  storehouse  of  fat,  35; 

as  a  detoxicator  (unpoisoner),35; 


519 


INDEX 


Liver  — 

diseases  of,  137-149; 

torpid,  137. 
Lock-jaw,  395. 
Locke,  Dr.  E.  A.,  125. 
Locomotor  ataxia,  265. 
Lumbago,  340. 
Lumbar  puncture,  269. 
Lungs,  15,  1 8; 

edema  of  the,  58. 
Lusk,  Professor  Graham,  in,  124. 
Lymph  glands,  diseases  of,  304. 

Macule,  447. 

Magnesium  sulphate,  135. 
Malaria,  382-389; 

diagnosis  of,  384; 

estivo-autumnal,  386; 

forms  of,  384; 

tertian,  385. 
Malignant   tumors  not  inherited, 

182. 
Malnutrition  because  of  bad  teeth, 

89. 
Manic-depressive   psychosis,    233; 

phase,  in  manic-depressive  psy- 
chosis, 236; 

state,  233. 
Marasmus,  510. 
Mastoid  operation,  475. 
Measles,  357; 

and  tuberculosis,  357. 
Meat  in  diet,  122. 
Medical  treatment  of  peptic  ulcer, 

™     ?9*-  • 
Meningitis,  259; 

epidemic  cerebro-spinal,  262; 

from  otitis  media,  261; 

tuberculous,  260. 
Menopause,  501. 
Menstrual  disturbance,  204. 
Menstruation,  500; 

cessation  of,  205. 

Mercury  as  cause  of  Bright 's  dis- 
ease, 162; 

in  syphilis,  378. 

Metallic  dust  and  tuberculosis,  439. 
Microscopic  examination  in  syphi- 
lis, 370. 

Micturition,  painful,  176. 
Middle  ear,  473. 
Migraine,  285. 
Milk,  115; 

adulterated,  126; 


Milk  — 

epidemics  of  typhoid,  346; 

supplies,  49. 

Mixtures,  indigestible,  114. 
Moods,  218. 
Morphine,  140; 

acute  poisoning  by,  429; 

causes  pain,  425; 

habit,  sources  of,  424; 

habit,  symptoms  of,  429. 
Moron  group,  253. 
Mosquitoes  and  malaria,  382; 

breeding  of,  387; 

in  malaria,  387. 

Mucous  patches  in  syphilis,  371. 
Multiple  personality,  225. 
Muscles,  12; 

involuntary,  13. 
Muscular  strains,  443.    • 
Myopia,  469. 
Myxedema,  311. 

Naphtha  poisoning,  411.  < 
Nasal  cavities,  53; 

obstruction,  52. 
Near-sightedness,  469. 
Neo-salvarsan,  380. 
Nephritis,  161-172. 
Nerves,  7,  46; 

motor,  46; 

peripheral,  218; 

sensory,  46. 
Nervous  system,  47; 

system,  diseases  of  the,  218-288. 
Nervousness,  103; 

as  cause  of  diarrhea,  157. 
Neuralgia,  278. 
Neurasthenic  type,  221.     tj 
Neuritis,  276; 

alcoholic,  267,  277; 

pressure,  277. 
Nose-bleed,  480. 
Nutrition,  ill. 

Oatmeal,  124. 

Obesity,  511. 

Occupational  neurosis,  444,  445; 

skin  diseases,  444. 
Ocular  headaches,  469. 
Operation  in  toxic  goitre,  311. 
Opium  and  its  derivatives,  424-432. 
Optic  atrophy,  467 ; 

neuritis,  466. 
Optometrist,  the,  469. 


520 


INDEX 


Organ  of  balance,  474. 
Osteomyelitis,  333; 

septic,  333. 
Osteopathy,  328. 
Otitis  media,  472,  474. 
Ovarian  cysts,  198; 

tumor,  198. 
Ovaries,  38; 

removal  of,  199. 
Oversensitiveness,  220. 
Oxygen,  19. 

Pains  in  right  iliac  region,  150. 
Pancreas,  31. 
Pancreatic  duct,  139; 

juice,  31. 
Pancreatitis,  145. 
Papule,  447. 
Paralysis  in  lead  poisoning,  410; 

in  poliomyelitis,  274; 

"Saturday  night,"  277. 
Paranoia,  249. 
Paresis,  245,  372. 
Paronychia,  504. 
Pasteurization,  51. 
Patent  medicines,  208. 
Pawlow,  119. 
Pediculosis,  452. 
Pellagra,  127. 
Pelvic  bones,  9. 
Pelvis  of  the  kidney,  37. 
Pepsin  in  stomach,  30. 
Peptic  ulcer,  history  of,  97; 

ulcer  relieved  by  soda,  97. 
Perineum,  42; 

lacerations  of  the,  187. 
Peripheral  nerves,  diseases  of,  276. 
Peritonitis,  32,  142; 

general,  192,  216; 

pelvic,  192; 

septic,  216. 
Personal  hygiene,  493. 
Pertussis,  359. 
Pessary,  194. 
Petit  mal,  280,  281. 
Phantom  tumor,  226. 
Pharyngitis,  51. 
Pharynx,  21. 
Phlyctenular    conjunctivitis    and 

keratitis,  461. 
Physical  defects  of  school  children, 

86. 

Piles,  483. 
Pinworms,  342. 


Pleurisy,  dry,  65; 

purulent,  63; 

tuberculous,  64; 

with  serous  effusion,  65. 
Pneumonia,  66; 

in  alcoholics,  66; 

outdoor  treatment  of,  66. 
Poisons,  27,  407-433; 

swallowed,  489. 
Poliomyelitis,  273; 

results  of,  275. 
Potassium  iodide,  380. 
Pott's  disease,  314. 
Pregnancy,  abdominal,  202; 

complications  of,  204; 

extra-uterine,  201 ; 

hygiene  of,  203; 

normal,  40; 

pernicious  vomiting  of,  204; 

tubal,  41. 

Prince,  Dr.  Morton,  225. 
Pronated  feet,  338. 
Prostate  gland,  43,  44,  212; 

inflammation  of,  210. 
Prostatic  obstruction,  213. 
Proteids,  112. 
Pruritis,  447. 
Psoriasis,  453. 
Psychasthenia,  227. 
Psychoneuroses,  219; 

always  inherited,  220; 

traumatic,  228; 

treatment  of,  231; 

visceral,  229. 

Psychoneurotic  states,  219. 
Psychoses,  233-252; 

exhaustion,  240. 
Pubic  bone,  10. 
Puerperal  state,  psychosis  of  the, 

241. 

Purgation  in  appendicitis,  152. 
Purgatives,  134,  135. 
Purpura,  302. 
Pus  pockets  about  teeth,  87; 

tube,  189. 
Pustule,  447. 
Pyelitis,  175,  177.. 
Pyorrhea  alveolaris,  84. 
Pyosalpinx,  189. 

Quinine  in  malaria,  389, 
Quinsy  sore  throat,  50. 


Railway  spine,  228. 


521 


INDEX 


Recreation,  501. 
Rectocele,  195. 
Rectum,  29,  42; 

cancer  of,  512. 

Red  rash  in  scarlet  fever,  354. 
Refraction,  errors  of,  469. 
Resistance  to  disease,  85. 
Respiration,  18,  19. 
Rest  after  food,  128; 

before  food,  128. 
Retina,  458,  465. 
Rheumatism,  326,  333; 

acute,  48; 

and  dental  disease,  87. 
Ribs,  7. 
Rice,  food  value  of,  123; 

polished,  127. 
Rickets,  318. 
Riggs'  disease,  84. 
Russian  oil,  135. 

Sacro-iliac  strain,  335. 

Sacrum,  IO. 

"Saddle-nose"  in  syphilis,  372. 

St.  Vitus  dance,  506. 

Saliva,  120. 

Salivation  from  mercury,  380. 

Salpingitis,  189; 

gonorrheal,  189; 

results  of,  189. 
Salt  in  Bright's  disease,  168. 
Salvarsan,  375. 
Salvarsanized  serum,  271. 
Scabies,  453. 
Scapula,  5,  8. 
Scarlet  fever,  161,  353. 
Schick  test,  352. 
Sciatica,  336. 
Scoliosis,  337; 

treatment  of,  337. 
Scurvy,  127. 
Self-centredness,  221. 
Semicircular  canal,  472,  474. 
Sepsis,  345,  389; 

operative,  391; 

puerperal,  184,  391; 

wound,  391. 
Septic  hand,  390; 

sore  throat,  48. 
Septicemia,  389; 

from  deep  abscesses,  392. 
Septum,  nasal,  54. 
Serum,  anti-tetanus,  397; 

salvarsanized,  271. 


Shingles,  506. 

"Shock,"  77,  169. 

Shoulder  stiff  and  painful,  505. 

Sick  headache,  285. 

Sinus,  64. 

Skeleton,  2. 

Skin,  diseases  of,  447-456. 

Sleep,  493. 

Smallpox,  402. 

Soda  in  peptic  ulcer,  97. 

Spastic  spinal  paralysis,  272. 

Spermatic  cord,  43. 

Spermatozoa,  39,  40,  42,  44. 

Spinal  column,  6; 

cord,  7,  46; 

cord,  diseases  of,  265-276; 

syphilis,  265. 

Spine,  tuberculosis  of,  314. 
Spleen,  35. 

Splenectomy  in  anemia,  299. 
Sprains,  484. 
Spraying  the  throat,  51. 
Squints,  468. 
Stammering,  510. 
Starvation,  511; 

in  appendicitis,  151; 

in  diabetes,  291. 
Sterility,  189,  210. 
Stiff  neck,  340. 
Still  birth,  510. 
Stomach,  29,  95; 

cancer  of  the,  95; 

disease,  rare,  103; 

symptoms,  common,  103; 

trouble,  144; 

trouble,  acute,  109; 

tube,  101; 

ulcer  due  to  streptococci,  87; 

use  of,  30; 

washing,  102. 
Streptococcus,  48,  68,  394; 

disease,  162; 

in  appendicitis,  149; 

infections,  506. 
"Stroke,"  77. 

Sunlight  for  tuberculosis,  314. 
Sunstroke,  486. 
Syphilis,  75,  306,  363-381; 

acquired,  369; 

congenital,  91,  366; 

cure  of,  374; 

dark-field  microscope  in,  370; 

gummata  in,  372; 

in  the  larynx,  93; 


522 


INDEX 


Syphilis  — 

in  the  nervous  system,  373; 
of  bones,  317; 
of  liver,  148; 
of  tongue,  92; 
treatment  of,  375. 

Tabes  dorsalis,  265,  372; 

dorsalis,  treatment  of,  269-271. 
Tapeworm,  341; 

fish,  342. 

Tapping  the  chest,  65. 
Taste,  in,  119. 
Teeth,  84; 

bad,  cause  of  dyspepsia,  89; 

for  teeth's  sake,  90; 

Hutchinsonian,  90; 

in  relation  to  tuberculosis,  89, 91 ; 

unerupted,  88. 

Terminal  infection,  147,  395. 
Testicle,  42,  44. 
Tetanus,  395; 

how  to  avoid,  396. 
Throat  culture  in  diphtheria,  350; 

syphilis  of  the,  93. 
Thyroid  gland,  diseases  of,  306-312. 
Thyrotoxicosis,  307. 
Tobacco,  417. 
Tomatoes,  125. 
Tongue,  diseases  of,  92. 
Tonsil  infections,  25. 
Tonsillectomy,  354. 
Tonsillitis,  48,  49. 
Tonsils,  25,  48,  53; 

as  a  defect,  53; 

hypertrophied,  51; 

lingual,  52; 

removal  of,  50. 
Tourniquet,  harm  from,  478. 
Towns-Lambert  treatment,  for  al- 
coholism, 432; 

treatment,  for  morphinism,  432. 
Toxic  amblyopia,  471. 
Trachea,  21-23. 
Trachoma,  471. 
Transfusion,  300; 

of  blood  in  anemia,  298. 
Trichiniasis,  339. 
Truss  in  hernia,  159. 
Tuberculosis,  57,  138; 

and  dust,  437; 

and  the  teeth,  89,  91; 

of  lungs,  107; 

of  tongue,  92. 


Tuberculous  glands,  305. 
Turbinate  bones,  54. 
Typhoid  carrier,  347; 
fever,  143. 

Ulcers,  syphilitic,  82. 
Unconsciousness,  485. 
Uremia,  164,  167,  172. 
Ureter,  37. 
Urethra,  38,  43. 
Urinary  organs,  the,  36. 
Urination  painful,  173,  176. 
Urine,  bloody,  179; 

pus  in,  174; 

the,  36. 
Urticaria,  454. 
Uterus,  38,  42; 

cancer  of,  183; 

cervix  of,  42; 

fibroid  of,  180; 

inflammation  of,  184; 

malposition  of,  42; 

misplacements  of,  208; 

prolapse  of,  196; 

tears  in,  42. 

Vacation,  502. 
Vaccination,  403,  405;  / 

anti-typhoid,  349. 
Vagina,  39. 
Vaginitis,  196. 
Varicella,  358. 
Varicocele,  214. 
Varicose  ulcer,  81; 

veins,  80; 

veins,  effects  of,  81; 

veins,  treatment  of,  81. 
Vasomotor  rhinitis,  504* 
Veins,  16; 

valves  in,  32. 
Vertebrae,  7. 
Vertigo,  259. 
Vesicle,  447. 

Vicious  circle  in  disease,  104. 
Vitamins,  127. 
Vitreous  humor,  458. 
Vocal  cords,  21. 
Voit,  122. 
Vomiting,  47. 
Vulvo-vaginitis,  197,  362. 


Wassermann  test,  70,  272,  375. 
Water,  distilled,  126; 

epidemics  of  typhoid,  346; 


523 


INDEX 


Water  — 

iced,  118; 

with  meals,  118. 
Whooping-cough,  359; 

and  tuberculosis,  360. 
Widal  test,  347. 
Windpipe,  21. 
Wool-sorter's  disease,  398. 


Worm,  round,  342. 

Wrist  drop  in  lead  poisoning,  410. 

X-ray  examination,  100; 
in  cancer  of  stomach,  96; 
in  leucemia,  302; 
in  peptic  ulcer,  98; 
in  toxic  goitre,  310. 


YC>I 10598 


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